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bie No. (New Series, Published June, 1934

WATTS EDEN,

stablighe 02 MEDICA,

The Journal of
Obstetrics and
_ of the British cai

C.P.,F.C.0.G. D. DOUGAL ., M.C., C-0.G.
F.R.C.P. Sir EWEN JOH MACLEAN F.RC.P., F.C.0.G
T. GEORGE Esq., M.D., F.CO0.G.
O.G. J. YOUNG, D.S.0
-COMYNS BERKELEY, M.D., F.R.C.P., F-R.C.S., M.M.S.A, (Hon:), F.C.0.6.

Director of the Review of Current Literature
FREDERICK ROQUES, M.D., M.Ch., F.R.C.S., M.C.0.G.

M.M.G.A. (Hon.), F.C.0.G.
BLAIR BELL, M.D., F.R.C.S., F.C.

CONTENTS.

Macafoc, M.B., F.RCS.L, FRCS, (Eng.). Caltical Stacy

Results of 122 Consecutive Hysterectomies. 333.
Sullivan, B.A., M.D., M.Sc, (West. Ont.), F-R.C.S. (Edin.), W. P. Tew,

°MLB. (Tor.), F.R.C.S. (Edin.), M.C.0.G., and B. M. Watson, M.D., M.Sc.

(West. Ont.), F.R.C.P: (Edin.). “The Bilibrubin Excretion Test: of Liver

Bunction in Pregnancy.” 347

‘Bote M.D. (Aberdeen), D.P.H.., ‘and Albert Sharman, MD.,

M.C.0.G. ‘‘The of the Vagina in the Human Subject.’’

“Douglas H. MS: “(Lond.), MRCP. (Lond.), F.R.C.S. (Eng.),

Origin of.Columnar Epithelium in the Graafian Follicle and
its relation to the Histogenesis of Ovarian Cysts.””. 385

Oseph S. Mitchell, B.A., B.Ch. (Cantab.). “Some Aspects of the Chemistry of
Haematocolpos Fluid.’ 390
Ss beac M.D, “Ligatars of the Open Abdominal End of the Fallopian
in Cases of Incipient Salpingo-Peritonitis.” 396
“Carcinoma of the Cervix Uteri in Pregnancy-and Labour’: Catiton
SOldfield. (II), Andrew Claye. (II), Comyns (IV), Prof.

W. W. Rooy ... S400, 40T, 402, 4047
De Sa, M.D., F.C, “Spontaneous Rupture of a Uterus, with
Report of a Case.”’ 406

MiMathecon, F.R.C.S, (Eng), “An Unusual Case of Intestinal Obstruction.” 4t0
Coleman, O.B.E., F.R.C.S., Edinburgh. ‘‘Uterns Bicornis Unicollis:

“Attesia of the Internal. Os: Retained Menses: Hysterectomy.’’
L.. I. Bublitschenko. ‘‘Abortion and Sterility.”’
Probodh Chandra Das, “Hydatidiform Mole “in & ‘Young
420

Adolphe Pinard 422: British ‘Gynaecological ‘Visiting Society 424:
Hospital Reports 427; Book Reviews 433: Review: of Current Literature. 443;
of Societies.

SHERRATT & HUGHES, MANCHESTER.

Price 10/8 net. 33 Annual Subscription, £2 12s. 6d. post free.
Colonies and Abroad, £2 15s. od. ~~ free. Published Bi-Monthly.

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a
:

The Journal of

Obstetrics & Gynaecology
of the British Empire

VOL. 41, No. 3 NEW SERIES JUNE, 1934

A Critical Study of the Results of 122 Consecutive
Hysterectomies.

C. H. G. Macaree, M.B., F.R.C.S.1., F.R.C.S. (Eng.),
F.C.0.G.

Assistant Gynaecologist, Royal Victoria Hospital, Belfast;
Assistant Obstetric Surgeon, Royal Maternity Hospital, Belfast.

Two authors, Davis and Cusick,’ in reviewing the subject of
hysterectomy, start their paper with the following paragraph:

‘The scientific attitude in hospital work would be measurably
improved if there were an obligatory requirement for a yearly,
five-yearly, and 10-yearly group study of at least five per cent
of the major standardized operations. Improved studies of cases
would be a natural result, a more efficient system of record-
making would follow, availability of the records would be
improved and a worth-while follow-up system would be sup-
ported. . . . The follow-up problem involves expense and
painstaking effort which has no immediate tangible value in
hospital financing. Its value must be credited to the patient and
doctor.”’

This paper is a review of 122 consecutive hysterectomies
performed by myself in the Ulster Hospital, Royal Victoria
Hospital, and in private practice, excluding Wertheim’s hyster-
ectomies and those performed for obstetrical emergencies. It also
includes a follow-up of 110 of these cases, the other cases having
been operated upon too recently to be of value from this point of
view.

333

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TaBLe I.
Indications for operation.

F tumours :
Fibroid and endometrioma
Fibroid and ovarian tumours
Fibroid and sarcomatous cervical polyp
Cancer of the uterine hile
Fibrosis uteri

Tumours of the
Endometrioma

Sarcoma of the uterus
Inflammatory pelvic disease
Suspicious cervix (microscopic) ...
Developmental abnormality

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HERO

nN |
N

Total

Fibroid tumours, either alone or complicated by other
tumours, were the indication in 69 per cent of the cases.
Malignant tumours formed 11.4 per cent of the cases. Endo-
metrioma alone or complicated by fibroids occurred in 10.6

per cent.
TABLE II.
Main symptom.

cent

Abnormal bleeding ...
Pain or discomfort ...
Tumour
Digestive symptoms
Bleeding and pain ...
Urinary symptoms ...
Leucorrhoea

This table simply proves what has been mentioned times
without number, that any menstrual irregularity, especially in
women over 30 years of age, has usually a pathological basis
which should be sought for and dealt with before treating the
patient with ovarian extracts or ergot.

Abnormal bleeding was the main symptom of fibroids in a
large percentage of cases, but some American authors do not
agree that this is always so. Davis and Cusick,’ for example,
say that abdominal and pelvic pain, while not recognized as a
symptom of fibromyomata by most textbooks, occurred much
more frequently in their series than any other symptom. The
frequency of this symptom in their series was 65 per cent.

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A CRITICAL STUDY OF HYSTERECTOMY

In my series of cases whether pain or bleeding was the main
symptom depended on the situation of the tumour. In those
cases in which pain was the main symptom the tumour was
either subserous, pedunculated, or had undergone degeneration.
When the tumour was encroaching on the endometrium haemor-
rhage was always the main symptom.

III.
Type of operation.

Number of cases Percentage of total
Total hysterectomy 76 62.3
Sub-total hysterectomy ...... 40

In cases requiring hysterectomy I think the total operation is
the better from every point of view, and when at all possible I
should always prefer to do it. The above Table includes many
of my earlier cases, and the fact that 37 per cent of the operations
performed are of the sub-total type illustrates my early inexperi-
ence. Read and Bell,* in a recent paper on this subject, give
inexperience in gynaecological surgery as one of the indications
for the sub-total operation.

As one gains experience and judgment the percentage of sub-
total operations is bound to fall, for example, of the operations
performed in this series during the past year, over go per cent
have been of the total variety.

There are cases in which the sub-total operation is unquestion-
ably safer than the total, e.g. in cases with extensive involvement
of the pelvis by endometriomatous tumours, when the rectum is
densely adherent to the lower part of the uterus and cervix, in
stout nulliparous patients, and in some benign cases when the
poor general condition of the patient indicates the shorter and
easier operation.

In this series there has not been a case of cancer developing
in the cervical stump following the sub-total operation, but it is
too early to say that this disastrous complication may not occur.
Since commencing this paper I have seen three such cases
operated upon by other gynaecologists.

Spencer, in commenting on this fact, states, ‘‘the truth
is that the advocates of the sub-total operation cannot state the
number of cases in which carcinoma occurs in the stump without

335

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JOURNAL OF OBSTETRICS AND GYNAECOLOGY

an inquiry into the after-history of every one of their cases for
a period of at least 30 years subsequent to the operation.”’

Fullerton and Faulkner,’ in referring to the possibility of
cancer developing in the cervical stump after sub-total hyster-
ectomy, say that many of these cases occur very soon after the
operation, suggesting the presence of the cancer in the cervix at
the time of operation.

Read and Bell,” in a recent paper discussing the sequelae of
the two operations, say, ‘‘not only is sub-total hysterectomy
more liable to remote complications but also that the mortality
rate of the operation would be considerably raised if the deaths
due to subsequent malignant disease of the cervix were
included.’’ The importance of this can be realized from the
figures from radiation centres for cases of cancer of the cervical
stump attending for treatment. It has been found that in from
three to eight per cent of the patients suffering from cervical
cancer and attending for treatment the disease has arisen in that
portion of the cervix left after sub-total hysterectomy.”

Reading American literature on the subject of hysterectomy,
one is impressed with the fear that many authors have of per-
forming the total operation because of injury to the ureters,
whereas in this country the total operation is strongly favoured
by many authorities.

The decision to perform sub-total hysterectomy should not
be taken without being satisfied beyond a doubt that the con-
dition of the cervix at the time of the operation warrants it, or
without performing a preliminary curettage to exclude the possi-
bility of an unsuspected carcinoma of the body of the uterus.

MorRTALITY.

There were two deaths in 122 cases or 1.6 per cent. One
case died from a pulmonary embolus following sub-total
hysterectomy for fibroids and an extensive endometrioma. This
patient was difficult to anaesthetize, was cyanosed throughout the
operation and died very suddenly a week later. The second
case died from shock. This patient was 58 years of age and
had, in addition, a large ovarian cyst adherent to bowel, uterus
and bladder, probably due to acute pelvic peritonitis. The
appendix was also acutely inflamed. A sub-total hysterectomy,
necessary on account of the fixity of the tumour to the uterus,
was a very small part of the operation, and, presumably, was
not in itself responsible for the patient’s death.

There were not any details among 76 cases of total hysterec-

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A CRITICAL STUDY OF HYSTERECTOMY

tomy. Mortality figures of other writers vary very much. Davis
and Cusick,’ in a series of 335 cases performed by 35 different
operators, show a mortality-rate of 4.5 per cent.

Burch and Burch,” reviewing 200 cases, give a rate of 4.5
per cent. Spencer*® in his series, which were all total hyster-
ectomies, had a death-rate of 1.8 per cent and in his paper
quotes Lockyer as having a mortality of 1.45 per cent. Worrall,°
in a series of 532 cases operated upon over a period of 18 years,
has a mortality-rate of 0.563 per cent. This is the best series
so far published.

Pulmonary embolism is still a dreaded complication of hyster-
ectomy and it seems to be more liable to occur after the sub-total
than after the total operation.

Read and Bell,’ investigating 2,344 cases operated upon in
the Chelsea Hospital for Women, found that this complication
caused 33 per cent of the deaths following the sub-total opera-
tion, while in the case of total hysterectomy it caused death in
only Io per cent of fatal cases.

TABLE IV.
Mortality.
Per cent

Davis and Cusick... 4168

In my experience, the type of patient likely to have post-
operative complications, especially pulmonary embolus, is the
patient who has a uterus containing several fibroids and which
is fixed to the other pelvic organs by endometriomatous or
inflammatory adhesions. The impaired mobility which results
from such adhesions adds greatly to the operative difficulty, is
liable to cause increased shock, and adds to the risk of injury to
bowel and ureter.

In cases of endometrioma, there is the added risk of ileus as
a result of extravasation of the retained menstrual fluid which is
very irritating to the peritoneum.

One of the most important points in the prevention of post-
operative complications is that the anaesthetic should be

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JOURNAL OF OBSTETRICS AND GYNAECOLOGY

administered by a trained anaesthetist, because the patient who
is straining and cyanosed throughout the operation is the patient
who is likely to develop a pulmonary embolus. The skilful
administration of anaesthetics has been a large factor in securing
the smooth and rapid convalescence of the great majority of the
patients in this series, and I am indebted to all the anaesthetists
concerned.

COMPLICATIONS.

There were relatively few complications during the three
weeks following the operation. Seven cases (including the two
patients who died) showed departures from the usual type of
convalescence, i.e. 5.7 per cent.

Of the complications associated with the total operation, two
are peculiar to the operation, and one is a risk of any abdominal
section.

‘Complication Sub-total
Acute gastric dilatation
Secondary haemorrhage from waging’ vault
Abscess in vaginal vault ...
Abscess in rectal sheath ...
Septic rash
Shock (death) .
Pulmonary embolus ‘Geath) (one died)

The complication of dilatation of the stomach was cured by
gastric lavage, and that of secondary haemorrhage from the
vaginal vault by securing the vessel with a suture. In one case
a small abscess developed in the vault of the vagina, but apart
from delaying the patient’s discharge from the nursing home
there was not any other serious consequence. Of the complica-
tions associated with the sub-total operation, the abscess in the
rectal sheath followed a haematoma, probably: due to piercing
a vessel with the ‘‘through and through’’ sutures. The patient
who developed a generalized septic rash caused great anxiety.
She had multiple fibroids and an unexplained fever three
weeks before operation. Operation was undertaken after this
had subsided, and four days later she developed a rash on her
buttocks, following enemata, which spread all over her body
and was associated with a temperature of 103° F. and a pulse-
rate of 140. There was not any evidence of peritonitis and the

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TABLE V.
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A CRITICAL STUDY OF HYSTERECTOMY

abdominal wound was normal. Following the administra-
tion of anti-scarlatinal serum the temperature gradually fell and
there was general desquamation. There were two cases of pul-
monary embolus, one of which died, and one case of shock,
which also died.

There were not any cases of urinary fistula in the series. Two
of the cases required blood-transfusion before operation.

From my own experience the mortality of uncomplicated
hysterectomy should be about one per cent. The two deaths in
this series were in cases complicated by adhesions and additional
tumours, which added to the operative difficulty or even over-
shadowed that of the actual hysterectomy. They were also diffi-
cult to anaesthetize.

AGE OF PATIENTS.

The average age for the whole series was 45} years. The
average age for patients operated upon in hospital was some-
what higher than that of the patients operated upon in private
practice.

In a hysterectomy, either total or sub-total, one question
always arises: “‘Should an ovary or both ovaries be conserved ?”’
The problem in a large number of cases is settled for the
operator on opening the abdomen, because both ovaries may be
the seat of extensive cystic disease or may be involved by
endometriomatous tumours or by inflammatory adhesions. In
such cases it is much wiser to remove both ovaries, especially in
a patient at, or past, the menopause. One great advantage of
removing the ovaries is that it makes the operation easier and
the peritonizing of the pelvic floor more complete. There is also
the advantage that one removes an organ in which tumours can
develop in later life. Most gynaecologists have had _ the
unpleasant experience of having to remove ovaries which have
been conserved and later become diseased, and this can be a
very difficult operation, especially when it is the left ovary. The
ovary becomes matted over with adhesions and the sigmoid
flexure has a most unfortunate habit of wrapping itself round
the organ. The difficulty experienced in removing conserved
ovaries has perhaps something to do with the large number of
cases in which the ovaries have been removed at the primary
operation in the series.

In women who are in the early thirties, it is probably better
to conserve one ovary and, for preference, the right.

The supposed advantage (I say “‘supposed’”’ in view of what
I have to say later) of conserving both ovaries is that the meno-

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JOURNAL OF OBSTETRICS AND GYNAECOLOGY

pausal symptoms associated with their removal are not manifest
immediately or are considerably alleviated. It has been observed
by many surgeons that the menopause appears prematurely
after hysterectomy whether. the ovaries have been conserved
or not.

Murphy and Sessums,’ investigating the surgical menopause
in patients operated upon before the age of 36, with conservation
of one or both ovaries, found that 43.9 per cent experienced hot
flushes before the age of 40. These authors state that this per-
centage was approximately eight times that occurring in a group
of women of corresponding ages not operated upon. In another
paper* they state that flushes were more common, more severe
and appeared sooner after bilateral than after unilateral 6ophor-
ectomy, but they think that the surgical menopause was shorter
after associated bilateral 6ophorectomy than after hysterectomy
with ovarian conservation.

Polak,’ in a paper which deals with 73 cases which had to be
re-operated upon for pathological conditions of conserved ovaries
within five years of the primary operation, discusses the end
results of the conserved ovary. He says, “‘a conserved ovary,
if unhealthy, will leave the patient in a worse state mentally,
nervously and physically than if total extirpation had been
done.’’ He thinks that when a patient has reached or passed
the age at which the menopause should occur, total ablation
gives the best results. Polak agrees that theoretically ‘‘the loss
of the ovaries means the loss of sex influence to the individual,
with all the grave disturbances in general metabolism which this
loss signifies, and the earlier in life the greater the calamity, but
practically the patient’s well-being may be seriously impaired by
routine conservation.”’

Of the six patients in my series, in whom one ovary was
conserved, one patient operated upon four years ago was 41 at
the time (but did not look it). This patient developed meno-
pausal symptoms one year later which lasted for 18 months,
were mild in character, and since then she has been very well.
Two patients were operated upon two years ago and have not
had any menopausal symptoms. Of the other three, two were
operated upon 18 months ago and one less than a year. None
of these have had any menopausal symptoms. These six
patients were the youngest in the series, the average age being
33, and the ovaries conserved were not, to the naked eye,
pathological. So far none of these patients has developed any
pathological symptoms associated with the conserved ovary and

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A CRITICAL STUDY OF HYSTERECTOMY

their menopausal symptoms have been absent or mild in degree.
In the remaining 116 cases both ovaries were removed at the
time of operation, but most of the patients were either at, or past,
the menopause or had pathological ovaries.

TABLE VI.
Follow-up (110 patients).

Died since operation Ses 5
Replied to questionnaire or interv

In following up these cases four objects were in view: (a)
to ascertain the character and, when possible, the duration of the
surgical menopause; (b) the incapacity following the operation;
(c) whether the cervical stump in cases of sub-total hysterectomy
has caused any trouble; and (d) the condition of patients
operated upon for carcinoma of the body of the uterus.

Of the 110 cases followed up four were untraceable and five
were dead, leaving 101 who were either seen personally, or com-
municated with by letter or through the patient’s own doctor.

TABLE VII.

"Age of patient Years after
Cause of operation Cause of death at death operation

Fibroid Haemocchagic: « enteritis 44 4
Fibrosis uteri Cardiac and renal disease 53 5
Sarcoma Cerebral haemorrhage 68 2%
Fibrosis uteri Coronary thrombosis 56

Cancer of uterus Recurrence ?60 I

MENOPAUSAL SYMPTOMS.

This investigation was started with the preconceived idea that
the removal of both ovaries, even in a patient at or about the
menopause, led to menopausal symptoms, more, severe than
those of the natural menopause.

Ninety-five of the patients followed-up tna both ovaries
removed and these are divided into three classes. The meno-
pausal symptom inquired for was flushing, which is the
commonest and most distressing symptom complained of.
According to this symptom the patients have been divided into
those who have had severe, mild, or not any flushes.

A case was regarded as severe in which the flushes were of

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JOURNAL OF OBSTETRICS AND GYNAECOLOGY

{frequent occurrence and lasted over one year; a mild case was
one in which the flushes lasted for only a few months and were
infrequent. The following table gives the figures under these
headings.
TaBLe VIII.
Menopausal symptoms.
Ninety-five cases with removal of both ovaries,

Severe Mild Absent
33 28 34

It will be seen that 64 per cent of patients had menopausal
symptoms, but that in only about 34 per cent were these
regarded as being severe. Just under 36 per cent of the patients
stated that they had not had any symptoms, i.e. flushes. The
highest proportion of patients not exhibiting flushes occurred
among a series of private patients. Among the hospital cases the
type of patient in whom one would have expected to find most
symptoms, i.e. nurses, had none. One patient operated on at
the age of 65 (menopause 15 years previously) developed flushes
which are still present at the end of two and a half years.
Another patient who had severe flushes and headaches before
her operation is now completely relieved.

Martindale,’ in a paper on the artificial menopause, found
that 41.9 per cent of patients in whom one or both ovaries were
conserved at operation did not have any flushes, but her series
in which both ovaries were removed was too small to form a
comparison.

Murphy and Sessums’ found that hysterectomy before the age
of 40, even when the ovaries were conserved, hastened the
menopause. They showed that 53.2 per cent of patients with
conserved ovaries had menopausal symptoms before 4o and that
the average time of onset after the operation was 15.7 months.

These figures given in the foregoing made one rather curious
to know what exactly were the figures for the normal menopause
under the same headings. For this purpose, ‘‘An Investiga-
tion of the Menopause in 1,000 Women,’’'' conducted by
the Council of the Medical Women’s Federation, may be
quoted. This investigation showed that the most frequent
symptom associated with the menopause was flushing. It also
showed that single women are more likely to pass through the
menopause easily than married women.

The average number of women, married and single, who pass

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A CRITICAL STUDY OF HYSTERECTOMY

through the normal menopause without symptoms is 15.8
per cent, but the average for single women is 20.4 per cent. It
is also shown that the duration of the flushing period is very
variable; in the majority it lasted about two years, but some
women between 70 and go years old have never been free from
flushing since the menopause.

From these figures and the literature one might conclude that
flushing, which is the most troublesome feature of the meno-
pause, is less in the artificial than in the natural menopause.
Against this conclusion one has to remember that the average
age for this series was 45} years and that, therefore, some of the
patients had already passed the menopause.

One might also find in these figures some justification for
removal of both ovaries at the time of operation, because even
conservation of the ovaries may only delay the onset of symp-
toms for a period of 15 months according to the authorities
quoted. The patient, therefore, has a menopause associated with
the removal of the uterus only to have a second menopause
associated with the atrophy of the conserved ovaries, possibly in
a relatively short time.

Of the patients operated upon in the past year it has been
found that those who have developed flushes did so within the

first month after operation. It is too early to say definitely, but
it has been my impression that those patients who have
developed moderately severe flushes soon after operation are
having a sudden, short menopause. Many of these patients have
said that at the end of five to six months their flushes were much
more infrequent and less severe, and in some cases had
disappeared.

INCAPACITY AS A RESULT OF OPERATION.

The incapacity resulting from the operation was estimated by
the length of time before a patient was able to resume her usual
duties. Taking the average for the ror patients, this was just
over five months. The shortest period was one month after
operation (two nurses) and the longest was 18 months.

This period of five months of incapacity does not to my mind
really represent the amount of disturbance that occurs as the
result of operation in those patients who develop severe meno-
pausal symptoms. In these cases one feels that it is probably
10 to 12 months before they really begin to feel quite well again.

When inquiring about the general health of these ror patients
since operation it was found that 85 were in excellent health,

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JOURNAL OF OBSTETRICS AND GYNAECOLOGY

and it was a very usual thing to hear a patient say that she had
not felt so well for years.

TABLE IX.
Health following operation.

Good Fair
85 15
Fifteen patients are in fair health, this being accounted for in
the following ways :—

Seven patients cannot give any reason for not feeling quite well. Some
of them have been operated upon under a year and their ages vary from

44 to 57 years.

Two patients had previous operations some months before the hyster-
ectomy, for inflammatory conditions, and would naturally have a prolonged
convalescence after the second operation.

Two have developed ventral herniae.

One patient has had two severe attacks of influenza since her operation
15 months ago and blames this for not feeling quite well.

One patient was very anaemic and emaciated and before operation
required a blood transfusion.

One patient was operated upon six years ago for carcinoma of the uterine
body and is now 71 years of age. She feels in excellent health, but has
a recurrence in the vagina which has responded to radium treatment.

One patient who had hyperpiesia before operation is still complaining of
headaches.

The patient who complains of bad health was 69 when
operated upon for a rapidly growing fibroid. The pathological
report showed a fibroid with a low degree of malignancy,
probably sarcoma, and six months after operation she has a
tumour in the lung although the abdomen is free from metastases.

CERVICAL STUMP.

In 46 cases of sub-total hysterectomy there were five patients
who had some symptoms as the result of leaving the cervix.
This was just over Io per cent of the cases. All the patients com-
plained of slight discharge or vulval irritation as the result of
this. So far not one of the cases has shown any signs of
developing carcinoma of the cervix.

In my series leaving the cervical stump does not seem to have
given rise to any serious symptom, and in most cases the patients
might not have referred to any discharge unless asked. There
is not any doubt, however, that there are serious potentialities
associated with the sub-total operation.

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A CRITICAL STUDY .OF HYSTERECTOMY

CANCER OF THE UTERINE Bopy.
There were 13 cases of cancer of the uterine body and three
cases of sarcoma.

Cancer 13.
Died 2 One untraceable, regarded as dead
Over five years a ee, Co One very well, one with recurrence
in vagina aged 71
Over four years... «. 2 Very well
Over three years... ... «s+ Very well
Two years and under... ... Very well
Sarcoma 3.
Two and a half years after operation
at 68
One with metastasis in lung

In the two cases of carcinoma in which the disease was very
advanced, the patients are alive over five years after the opera-
tion. In one there is a recurrence in the vagina which has
responded to radium, and this illustrates the importance of
keeping in touch with cancer cases after operation, and treating
any recurrence immediately. The other appears to be quite well.
One of the patients operated upon two years ago had a perfora-
tion at the fundus of the uterus, due to growth, to which small
intestine was adherent, and one was very doubtful whether to
remove the uterus or not. The patient has never been so well
and last summer was assisting at the harvest !

SARCOMA.

Of the three cases of sarcoma, one patient died of cerebral
haemorrhage at 68 two and a half years after operation.
Another is very well one and a half years later, and the third is
the case referred to with a metastasis in the lung.

CONCLUSION.

I do not wish to be regarded as an opponent of conservative
surgery, but I feel on very safe ground in advocating total in
preference to sub-total hysterectomy, unless in exceptional
circumstances. As Spencer* says, “The sub-total hysterectomy
is a nineteenth-century operation. May there disappear . . . that
opprobrium to gynaecology, namely cancer of the cervix left
behind by the sub-total operation.”’

In suggesting the removal of both ovaries at the time of the
hysterectomy one does not feel on such safe ground, but I still

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think that it is the best thing to do in women at or past the
menopause.

I would also make a plea for keeping in touch with all cases
of cancer of the body of the uterus as well as cancer of the cervix.
The case of cancer of the cervix is closely followed up, but the
case of cancer of the body of the uterus is liable to be neglected.
In view of recent experience, I think that these patients should
have more post-operative X-ray and radium treatment than they
have been given in the past.

In conclusion I should like to thank all the doctors who have
assisted me in inquiring about these patients, and Professor
Lowry for facilities given me for operating in the Royal Victoria
Hospital during the years I was on the auxiliary staff, and for
permission to use these cases in this paper.

REFERENCES.

1. Davis, J. E., and P. L. Cusick. ‘‘A critical study of hysterectomies.”’
Amer. Journ, Obstet. and Gynecol., 1930, xix, 246.

2. Read, Charles D., and Arthur C. Bell. ‘‘Hysterectomy, sub-total and
total.’’ Journ. Obstet. and Gynaecol. Brit. Emp., 1933, xl., 5, 749.

3. Spencer, H. R. ‘‘Total abdominal hysterectomy for myoma of the
uterus.”’ Brit. Med. Journ., 1932, i, 1157.

4. Fullerton, W. D., and R. L. Faulkner. ‘‘Hysterectomy.’’ Journ.
Amer. Med. Assoc., 1930, xcv, 1563.

5. Burch, L. E., and J. C. Burch. ‘‘Mortality in hysterectomy operations.”’
Amery, Journ. Obstet. and Gynecol., 1931, xxi, 704.

6. Worrall. ‘‘Total hysterectomy for non-malignant conditions.’’ Brit.
Med. Journ., 1933, i, 741-

7. Sessums, J. V., and D. P. Murphy. ‘‘Hysterectomy and the artificial
menopause.’’ Surg. Gynecol and Obstet., 1932, lv, 3, 286.

8. Sessums, J. V., and D. P. Murphy. ‘‘The surgical menopause after
hysterectomy with and without ovarian conservation.’’ Surg. Gynecol.
and Obstet., 1932, lv, 6, 728.

g. Polak, J. O. ‘‘A further study of the end results of the conserved
ovary.”’ Amer. Journ. Obstet., 1918, Ixxviii, 199.

10. Martindale, L. ‘‘The artificial menopause.’’ Brit. Med. Journ., 1933,
ii, 857.

11. ’’An Investigation of the Menopause in 1,000 Women.’’ Lancet,

1933, i, 106.

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The Bilirubin Excretion Test of Liver Function in
Pregnancy.

By C. F. Suttivan, B.A., M.D., M.Sc. (West. Ont.), F.R.C.S.
(Edin.), Meek Fellow in Obstetrics and Gynaecology.

W. P. Tew, M.B. (Tor.), F.R.C.S. (Edin.), M.C.O.G.
Associate Professor of Obstetrics and Gynaecology.

and

E. M. Watson, M.D., M.Sc. (West. Ont.), F.R.C.P. (Edin.),
Associate Professor of Pathological Chemistry, the University of
Western Ontario Medical School, London, Ontario.

THE association of degenerative changes of the liver and certain
of the toxaemias of pregnancy has prompted numerous investi-
gators to study the functions of the liver during pregnancy in an
attempt to discover some means, other than the usual methods of
clinical examination, which would serve as an indication of the
existence and the degree @f severity of the hepatic lesions. Thus,
it was hoped that a method might be established which could be
used as a guide in the elucidation of such problems as the diagnosis
and prognosis of the toxaemias of pregnancy, the grouping of these
into hepatic and nephritic types, the differentiation of neurotic
vomiting from toxic vomiting and, finally, as an indication for
surgical intervention. Unfortunately, a liver function test has
not as yet been devised which is capable of fulfilling these objec-
tives in a wholly satisfactory manner. The problem of develop-

’ ing a method which will reflect accurately the state of functional

efficiency of the liver is by no means a simple one. There are
certain fundamental reasons why hepatic efficiency tests may
never attain the same degree of usefulness as comparable proce-
dures employed in the clinical study of other organs, for example,
the kidneys. ;
Of the 20 or more tests which have been described for the pur-
pose of detecting alterations of liver function, six have received
general approval from the standpoint of clinical usage. These
have been applied in a more or less systematic manner in preg-
nancy and its complications by several observers who have
expressed varied opinions regarding their practical value. For
example, Cruickshank et al,’ de Wesselow,’ Stander,*® and Huwer"’

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consider hepatic efficiency tests in pregnancy to be of little or
no value. On the contrary, King* and Solomons’ claim for them
a distinct field of usefulness. Such a lack of agreement concerning
the efficacy of liver function tests is apparent throughout the
literature relative to the subject and is explicable in part at
least. Primarily, the liver subserves not a single function but
several functions. It is possible, theoretically, for one or more
of these functions to be at fault while the others remain intact.
Although much is known concerning the activities of the liver,
there are many details pertaining to the 7dle of this organ both in
health and in disease which are still but vaguely understood. It
seems that a considerable portion of the liver can be removed ex-
perimentally without serious ill effect upon the animal’s general
condition. While such experimentally produced lesions may not
be directly comparable to the preclusion of hepatic tissue by
disease, they do imply that considerable destruction of liver sub-
stance may occur without demonstrable evidence of functional in-
capacity on the part of the organ. Furthermore, the liver exhibits
rather active reparative powers. In response to the continued
action of certain noxious influences, providing the effect of these
be not overwhelming, compensatory hyperplasia of the paren-
chymal tissue ensues. Thus may be explained the normal results
of efficiency tests which are obtained at times in the presence of
actual hepatic disease.

In accord with degenerative tissue changes elsewhere, varying
grades of hepatic damage ranging from potential disability to
complete destruction may occur. Pregnancy entails such a radical
alteration of the maternal organism that structural and functional
deviations from the normal are inevitable. While all the visceral
organs no doubt partake in the process of accommodating the pro-
duct of conception, the kidneys and the liver appear to be those
which are most often embarrassed by the process. The efficiency
with which these organs carry on their functions under the handi-
cap of the pregnant state depends upon several factors such as the
presence of pre-existing pathological conditions, coincidental
lesions not necessarily related to the pregnancy and the effect
of certain deleterious influences directly dependent upon the preg-
nancy. Considering, therefore, the physiological strain to which
these organs are subjected even in normal circumstances during
pregnancy, it does not seem unreasonable to regard the naturally
occurring alterations of metabolism as the preliminary stages of
the more pronounced metabolic deviations which accompany the
state of intoxication. This viewpoint has been expressed by

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Kaufman,* who commented upon how little removed is toxaemia
from that which may be regarded as the normal metabolism in
pregnancy. Since the boundary between the normal and the
abnormal is often not readily definable, some means whereby
abnormal liver disturbance can be detected would doubtless be a
welcome asset to the clinician, but the fact that the livers of a
number of pregnant normal women have been found to react to
various tests in the same manner as diseased livers, makes the
problem of interpreting the significance of the results of hepatic
efficiency-tests in pregnancy exceptionally difficult.

Frequently a condition of latent incapacity of an organ can
be demonstrated by subjecting the organ in question to a degree
of functional strain within the limits of physiological endurance.
Well-known examples of ‘‘overloading’’ tests are used to study
the functional capacity of the kidneys and to detect abnormalities
of carbohydrate metabolism. Until recently, methods comparable
to these directed towards the liver have been concerned princi-
pally with the glycogenic function of this organ and its ability to
excrete certain dyes following their intravenous injection. In
some cases there does appear to be a correlation between the
degree of hepatic lesion and the tolerance for laevulose or galac-
tose. There are, however, certain factors other than the func-
tional integrity of the liver-cells which are concerned in the res-
ponse of the organism to these ingested sugars. Such tests have
been found to be of little practical value in pregnancy. Probably
the most extensively investigated test of hepatic function during
pregnancy is the phenoltetrachlorphthalein test and its successor,
the bromsulphalein test. According to King,* Krebs and Dieck-
mann’ and Siegel* this method is an aid in the investigation of
patients suspected of having toxaemia of pregnancy, but Smith*®
considered it unwise to attach a great deal of importance to the
results of the procedure.

Any test of vital function should be based upon physiological
concepts. The dye tests not only lack a physiological background,
but the participation of the reticulo-endothelial system of cells in
the removal of foreign pigments from the circulation is a factor
which cannot be assessed with accuracy in the human subject.

Recent developments have led to a better understanding of the
problems relating to hepatic and biliary disease due largely to the
introduction of improved methods of clinical investigation. One
of the major functions of the liver is concerned with the trans-
ference of bile pigment from the blood capillaries to the bile
capillaries for excretion. Pathological changes affecting the liver-

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cells may lead to interference with this function. Since the liver
is concerned to a large extent normally with the excretion of bili-
rubin, it would seem more logical, from the physiological point of
view at least, to attempt to test the functional integrity of this
organ by presenting to it for excretion a substance with which it is
normally prepared to deal, rather than something which is entirely
foreign to the organism. It was with this idea in mind, appar-
ently, that von Bergmann" in 1927 introduced the bilirubin ex-
cretion test which promises to be one of the most sensitive methods
as yet evolved for the evaluation of liver function.

THE BILIRUBIN EXCRETION TEST.

Briefly, the test is a measure of the rate of disappearance from
the blood-stream of a known small amount of pure bilirubin in-
jected intravenously. The necessary information is acquired by
estimating the concentration of bilirubin in the plasma before the
injection and at specified time intervals thereafter. Observations
prove that none of the injected bile pigment escapes from the
blood-stream by way of the kidneys. Also, there is not any evi-
dence that any of it is phagocytosed and stored by the reticulo-
endothelial system of cells such as occurs when certain foreign
pigments are introduced into the circulation. Since the injected
bilirubin does not pass through the renal epithelium and appar-
ently is not removed by widespread phagocytic activity, it seems
reasonable to assume that it is wholly excreted by the liver and
that the rapidity of its disappearance from the blood-stream may
be regarded as an indication of its rate of excretion and, there-
fore, as a rational index of the functional capacity of the liver.
While this test prepossesses a satisfactory physiological basis, it
may be open to criticism on the grounds that it interprets but one
phase of the liver’s activities, namely the ability to excrete bili-
rubin. There is probably some reason for the contention that it
is a mistake to judge the total function of an organ according to
the results of a test of a partial function. There is, apparently,
not any division of labour on the part of the parenchymal cells of
the liver, all being capable of participating in the several duties
performed by this organ. Consequently by means of the appli-
cation of the bilirubin excretion test, a clinically important major
function of the liver is the object of investigation.

The results of the bilirubin excretion test in a variety of liver
disorders have been reported by von Bergmann,"’ Eilbott'’ and
Harrop and Barron."* The pathological conditions so studied in-
cluded hepatic cirrhosis, chronic passive congestion, jaundice,

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hepatitis and anaemia. Retention of bilirubin was observed in all

of these abnormalities and the value of the test as a clinical aid
was demonstrated. Of particular interest are the data of Harrop
and Barron'* who were able to recognize liver insufficiency by
delayed bilirubin excretion when the commonly-used methods
such as the Van den Bergh, laevulose tolerance and bromsul-
phalein tests failed to give evidence of any abnormality. They
conclude that a “‘study of the bilirubin excretory power of the
liver is the most delicate method so far proposed for testing the
functional capacity of this organ.’’

Comparatively few critical observations concerning the appli-
cation of this test in pregnancy and its complications have been
published. Kaufmann‘ ' investigated two series of 25 and 26
normal pregnant women by this method along with other hepatic
efficiency tests and found that during the first half of gestation
little or no evidence of disturbed liver function could be demon- *
strated, but that during the second half of gestation abnormal
results were obtained in a considerable proportion of the women
tested. He did not consider such findings as indicative of patho-
logical changes, but regarded them rather as an expression of the
peculiar metabolism existent during pregnancy. Stroebe** studied
the liver function one month to three years post-partum in 24
women who had suffered from toxaemia of pregnancy before de-
livery and found that more than one-half showed an abnormal
retention of the intravenously injected bilirubin. The degree of
this so-called “latent hepatopathy’’ appeared to be related some-
what to the severity of the antepartum toxaemia, also to the length
of time intervening between delivery and the performance of the
test. The gradual return of the liver function to normal which
he observed was regarded as an indication of regeneration of liver
tissue. Hofbauer’® observed that 15 patients in the first half of
pregnancy responded in a normal manner to the bilirubin excre-
tion test, whereas 17 out of 20 during the second half of pregnancy
gave results which were abnormal according to his standards.
Soffer’’ found that of rr cases studied by the same method during
the first half of pregnancy, only one showed a retention after four
hours which was considered to be abnormal. Of 10 patients in
the second half, all except one showed abnormal retention of the
injected pigment. All but two out of ro normal pregnant women
showed a greater degree of retention of the bilirubin during the
second half of gestation than during the first half. Delayed excre-
tion of intravenously injected bilirubin in pregnant women ex-
hibiting toxic manifestations was noted by Watson.'*

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A comparison of the results obtained with the bilirubin excre-
tion test by these various observers is difficult because of lack of
a generally accepted standard of normal values. Those who have
used the test have apparently adopted standards according to
their individual experience.

It was with the object of acquiring some more or less definite
information concerning this method, particularly as regards its
possible applicability to the elucidation of some of the problems
in obstetrics, that the investigation described in this paper was
undertaken. There are presented below the results of 147 bili-
rubin excretion tests which were carried out on 80 women during
pregnancy and following confinement, and on 11 women of child-
bearing age who were not pregnant served as a control series.

EXPERIMENTAL PROCEDURE.

Cases for investigation were selected from the antenatal clinic
and from the wards of the Victoria Hospital, care being observed
to avoid individuals with conditions other than pregnancy which
might give rise to ambiguous results. For example, persons sus-
pected of having gail bladder disease or any hepatic disorder un-
related to the pregnancy were not considered; likewise, those with
cardiac disease, infections or varicose veins were eliminated.

For purposes of study, suitable cases were classified provision-
ally as normal (i.e. non-toxic) and toxic. The criteria upon
which this classification was based were as follows: A primi-
gravida was regarded as being ‘ normal ’ if her systolic blood-
pressure was I35 mm. or less on at least two separate occasions,
and if there was not more than a ‘ trace ’ of albumin in the voided
urine. A multipara was placed in the same category if her blood-
pressure did not exceed 140 mm. and the same urinary findings
prevailed. A patient was classed as ‘ toxic ’ if her blood-pressure
exceeded the above-mentioned limits or if one or more of the
following abnormalities existed: albuminuria, oedema, headache,
visual disturbances, gastric distress or vertigo.

The patients comprising the normal group consisted for the
most part of out-patients. They entered the hospital in the morn-
ing, fasting, and remained for about six hours during which time
a physical examination and the necessary laboratory procedures,
including the bilirubin excretion test, were carried out. When-
ever possible, the clinically toxic patients were detained for about
one week in order that a more complete investigation could be
undertaken. This comprised, in addition to the liver tests, a study
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BILIRUBIN EXCRETION TEST

urea concentration factor, two-hour specific gravity volume test,
phenolsulphonophthalein excretion, dilution and concentration
tests and certain blood-chemical estimations. In the case of a
seriously ill patient, or when delivery was imminent, this pro-
gramme could not always be completed. In every instance, how-
ever, the bilirubin excretion test was accomplished.

THE TECHNIQUE OF THE BILIRUBIN EXCRETION TEST.

The technique employed for performing the bilirubin excretion
test was that described originally by von Bergmann" with certain
modifications as suggested by Soffer,'’ together with one or two
additional improvements which developed out of personal experi-
ence with the method. Briefly, the procedure is as follows: An
amount of bilirubin equivalent to 1 mg. per kilogram of body
weight is dissolved in 15 c.c. of 0.1 M. solution of sodium car-
bonate, previously boiled and cooled to about 80°C. After the
pigment has dissolved completely, the solution, having further
cooled nearly to body temperature, is transferred to a 20 c.c.
syringe and injected siowly into a vein at the elbow. Untoward
effects of any kind have not been observed to follow such
injection. Blood samples are obtained immediately before the
injection and four minutes, thirty minutes, two hours, and four
hours afterwards. These samples, which are received in centri-
fuge tubes containing potassium oxalate, are centrifuged at once
and kept in a refrigerator until the final collection has been made.

The conc#htration of bilirubin in each sample of blood-plasma
is estimated by the method of Ernst and Forster'’ which procedure
consists essentially of the simultaneous precipitation of the plasma
proteins and the extraction of the bilirubin with acetone. For this
purpose 2 c.c. of acetone are added to I c.c. of plasma in a centri-
fuge tube. After shaking the plasma and acetone mixture, the
precipitate is removed by centrifugalization and the supernatent
liquid which contains the pigment is filtered directly into a micro-
colorimeter cup through a No. 40 Whatman filter paper and com-
pared with a standard composed of 1 in 6,000 potassium dich-
romate. It was found that clearer filtrates could be obtained if
the centrifuge tubes, following the removal of the protein, were
stoppered and chilled by immersion in a water-bath containing
lumps of ice for five minutes before filtration. The acetone
solutions must be protected from the light previous to making the
colour comparisons. All the estimations and colorimetric read-
ings were made and checked by the same two individuals.

It is true that this method of estimation includes not only the

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bilirubin but other pigments such as carotin and lipochromes
should these be present in the plasma, but in the cases reported in
this paper, any effect produced by such substances was minimized
by carrying out the tests with the patients in the fasting state.
Moreover, assuming any error due to the presence of these non-
biliary pigments to be constant throughout the period of the test,
their influence is removed completely by subtracting the result
obtained in the preliminary control sample from the values found
in the subsequent ones. Hence the bilirubin content of the speci-
men secured four minutes after the injection of the bilirubin minus
that of the control sample is 1egarded as representing the maxi-
mum increment caused by the added pigment and is consequently
recorded as 100 per cent. With this value as a basis, the findings
for the other samples are expressed accordingly. While the re-
sults so obtained represent the relative rather than the absolute
bilirubin concentrations, they do provide a representation of the
completeness of elimination of the injected bilirubin in a specified
time.

NorMAL RESULTS.

As has been intimated above, divergent opinions exist as to
the response of the normal individual to the bilirubin excretion
test. In their original work, von Bergmann" and Eilbott’* con-
sidered only a retention of over 10 per cent at the end of four
hours as indicative of liver impairment. Kaufmann®: ‘* regarded
a retention of 15 per cent after four hours as the liffit of normal,
while Stroebe'’ adopted the same figure for a three-hour period.
Harrop and Barron'* concluded that when bilirubin is injected
intravenously into normal individuals, it is totally excreted infrom
two to four hours. Consequently, they looked upon any reten-
tion at the end of four hours as suggestive of hepatic disability.
Hofbauer'® accepted 4 per cent after four hours as the limit of
normality, and Soffer’’ viewed anything greater than 5 per cent
retention four hours after the injection of bilirubin as pathological.

In order to establish a standard with which to compare the
results obtained in cases of pregnancy, a series of bilirubin excre-
tion tests was performed on 21 women of ages falling within the
child-bearing period who were not pregnant. The results of
these are shown in Table I. None of these women were acutely
ill, and none presented the symptoms or history of hepatic or
biliary disease; several were obviously normal individuals. It is
seen that out of the 21 cases complete elimination of the injected
bilirubin within four hours occurred in only two instances.

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BILIRUBIN EXCRETION TEST

Among the others quite a range of variation prevailed. With but
two exceptions, however, the amount of retention was Io per cent
or less. The average for the whole group is 5 per cent, which
happens to be the figure adopted by Soffer as the limit of normal.
In view of these findings, it is felt that a retention of ro per cent
of the bilirubin four hours after its injection should be regarded
as the maximum bound of the normal as originally suggested by
von Bergmann" and by Eilbott.**

RESULTS IN UNCOMPLICATED PREGNANCY.

Of the 58 cases of normal pregnancy studied, 11 were tested
in the first half of gestation and 47 in the second half. While
individuals were not examined during both the first part of their
pregnancy and the second part as well, it is obvious by a com-
parison of the results obtained in the two groups of cases that
there is a much greater tendency for abnormal retention of in-
jected bilirubin to occur during the second half of pregnancy than
during the first half. This is a fact which has been commented
upon by Kaufmann,° Hofbauer,'* and Soffer.'’ Of the 11 cases
observed during the early stages of pregnancy, only one gave a
result which may be considered to be pathological (Table II);
whereas 15 of the 47 cases tested in the later months were abnormal
(Table III). Fig. 1 shows the distribution of the findings at the
different periods during uncomplicated pregnancy.

RESULTS IN Toxic CasEs.

When a patient was judged to be toxic by one or other of the
criteria specified above, she was further classified as a case of
nephritic toxaemia or non-nephritic (hepatic ?) toxaemia accord-
ing to the results of the kidney function tests. Appreciating the
confusion which surrounds the nomenclature as applied to the
various toxaemias of pregnancy, it is considered that this simple,
comprehensive classification conforms best to the scope of the
present investigation. The results of the bilirubin excretion test in
these two groups of cases are presented separately.

1. Toxic cases with evidence of renal insufficiency (nephritic
toxaemia). There were nine patients who presented evidence of
impaired renal function as determined by several kidney function
tests. For the sake of brevity, the results of these tests are not
recorded, but in Table IV are shown the findings obtained with
the bilirubin excretion test in this group of cases. With but one
exception, they all fell within the normal ro per cent four-hour

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limit. Case No. 1, with 12 per cent retention, was a fatal case
of nephritic toxaemia. The bilirubin test was carried out 14 days
prior to her death. The liver, at autopsy, except for being rather
larger and of a darker colour than normal, presented nothing
remarkable in the gross. Microscopically, however, there was a
noticeable degree of passive congestion with dilatation of the central
veins and atrophy of the surrounding tissue. The peripheral cells
showed cloudy changes and there were small, scattered, well-
defined areas of focal necrosis. The kidneys showed marked dif-
fuse nephritis. It would seem reasonable to assume that in this
case the state of the liver, as observed post-mortem, did not repre-
sent its condition at the time that the bilirubin excretion test was
carried out- In any event, the relatively slight degree of func-
tional hepatic impairment as evidenced by only 12 per cent reten-
tion of bilirubin at the end of four hours in a case of pregnancy
toxaemia primarily nephritic in type is demonstrated.

2. Toxic cases without evidence of renal insufficiency (non-
nephritic [or hepatic?] toxaemia). In eight out of 14 cases of
toxaemia in which there was not any suspicion of serious renal
damage, there was evidence of defective liver function as indi-
cated by an abnormally high retention of bilirubin. These find-
ings are shown in Table V. Of particular interest is Case No. 28,
a primigravida, aged 20, who presented herself at the antenatal
clinic during the seventh month of her pregnancy, complaining
of frontal headache, blurring of vision, swelling of the ankles
and occasional attacks of vomiting and diarrhoea. The blood-
pressure was 155 mm. and the urine contained a ‘ trace’ of
albumin. The tests of kidney function disclosed normal results
and the circulatory system was normal. Only 4 per cent of the
injected bilirubin remained in the blood-stream after four hours.
Three weeks later she re-appeared at the clinic with a blood-pres-
sure of 178 mm. and marked albuminuria. Subjective symptoms
were absent at this time, however. After another week, which
was a fortnight before her expected date of delivery, she reported
again complaining of epigastric pains, mental confusion and blurr-
ing of vision. The blood-pressure had risen to 2t0 mm. and the
urine contained a large amount of albumin and numerous casts.
She was admitted to the hospital at once and the bilirubin excre-
tion test revealed a retention of 54 per cent of the injected pigment
after four hours. Projectile vomiting ensued and generalized
oedema could be demonstrated. The non-protein nitrogen was
25.0 mg. per 100 c.c. of blood. Thirteen hours after entering the

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BILIRUBIN EXCRETION TEST

hospital she was delivered of a stillborn infant, following which
her condition improved rapidly, the subjective symptoms disap-
pearing and the blood-pressure returning to the normal level. A
third bilirubin test was performed 12 days following delivery when
all the pigment was eliminated four hours after its injection.

That delayed excretion of injected bilirubin may serve as a
danger signal is suggested by the findings in Case No. 45 (Table
VII). This patient, aged 33, was tested six weeks after the begin-
ning of her ninth pregnancy at which time she was not experienc-
ing any toxic manifestations, but she showed 17 per cent retention
of bilirubin. In the absence of obvious clinical signs and symp-
toms, an explanation for this abnormal result was not forthcoming.
The case was at first listed among the early non-toxic group, but in
the light of subsequent developments she was reclassed as a case
of hepatic (?) toxaemia. Ten days later she was admitted to the
hospital with excessive and persistent vomiting, from which she
recovered following appropriate treatment, but after two weeks
she aborted. Careful questioning failed to elicit any information
which would lead to a suspicion that any extraneous influence
was responsible for the abortion. The Wassermann test
was negative. Toxic complications had been present during
several of her previous pregnancies. Nine days following the
termination of the pregnancy, a repetition of the test showed only
Q per cent retention of the pigment. The difference in the results
of the two tests favours the assumption that the delayed excretion
of bilirubin in the first one was related to an early stage of preg-
nancy toxaemia.

COMPARISON OF THE RESULTS BEFORE AND AFTER DELIVERY.
In 22 patients the bilirubin excretion test was carried out fol-
lowing delivery as well as before. Fourteen of these had normal
pregnancies, but in eight there was atoxaemic complication which
was classified in all cases except one, i.e. No. 47 (Tables IV and
VII), as hepatic (?) in type. Ten of the non-toxic patients in this
series showed abnormal retention of bilirubin antepartum; all but
three of these presented normal results following delivery (Table
VI and Fig. 3). Of the whole group of 14 non-toxic cases, all
save two exhibited less retention following delivery than during
the pregnancy. Of six toxic cases which showed abnormal reten-
tion of bilirubin antepartum, all but two gave normal findings
after delivery (Table VII and Fig. 4). Of the entire group of
eight toxic cases all but one showed less marked retention after

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delivery than before. Had the tests been repeated at longer inter-
vals following parturition, it is probable that a still more obvious
ultimate return to normal could have been demonstrated.

DISCUSSION.

It is doubtful if tests of hepatic function, such as the one des-
cribed in this paper, will prove to be of particular assistance in the
diagnosis, prognosis or treatment of the complications of preg-
nancy. The most recent addition to the already long list of liver
function tests, namely the bilirubin excretion test, which seems to
have acquired a degree of approbation in other fields of medicine,
has been applied in a limited number of obstetrical cases with the
result that its realm of usefulness may be appraised in much the
same terms as other hepatic efficiency tests. Since, in selected
cases, the method may provide information of distinct value, it
should not be discounted entirely as a practical adjunct to the
clinical methods in common use. The technical difficulties in-
volved in the performance of the test tend to limit its applicability.

Apart from the purely pathological aspects of the problem,
studies of the liver function in pregnancy have revealed some in-
teresting data. For example, there is, apparently, in many cases
at least, a certain amount of functional hepatic impairment during
clinically uncomplicated pregnancy, which disability is more pro-
nounced during the second half than during the first half of gesta-
tion; thus suggesting that the so-called ‘‘liver of pregnancy’’ is
as much a reality from the functional as from the anatomical
standpoint. That this impairment is temporary and presumably
due solely to the pregnancy is evidenced by the tendency for the
liver function to return to normal following termination of the
pregnancy. Whether this apparently natural hepatic derange-
ment initiates, in some individuals, trouble of a more serious
character is a probability worthy of consideration. That preg-
nancy does not produce any permanent liver damage is demon-
strated not only by an improvement in function immediately fol-
lowing delivery but by the observation that many women who
have gone through several pregnancies show a normal response
to the bilirubin excretion test. The latter fact has been remarked
upon by Soffer.'’ It is possible that the low reserve kidney, as
described by Williams,*’ possésses an analogy in the behaviour of
the liver during pregnancy.

- While a differentiation of the pregnancy toxaemias into neph-
ritic and hepatic varieties may be possible-on the grounds of the
358

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;

BILIRUBIN EXCRETION TEST

results of kidney and liver efficiency tests, too much reliance
should not be placed on these laboratory procedures alone. They
must always be interpreted in relation to the clinical state of the
patient, and due consideration must be given to the normally
occurring functional deficiency, especially as regards the liver
during the second half of pregnancy (Fig. 2). In a patient with
toxic manifestations, however, an abnormal result of a liver func-
tion test with normal kidney function would favour the existence
of hepatic lesions. Likewise, normal liver function in the presence
of disturbed kidney function would point to a nephritic disability.
Knowledge of this kind may be of value from the standpoint of
therapy or of affirming a prognosis.

Siegel* and King*' claimed to have been able to differentiate
hepatic types of pregnancy toxaemias from the nephritic types
by means of the dye excretion tests. Mackenzie** found difficulty
in making such a distinction by chemical examinations of the
blood and urine. He observed, however, that urobilinuria was
usually not present to a pathological degree in nephritic toxae-
mias but that it was generally found in the hepatic types. The
importance of urobilinuria in the vomiting of pregnancy has been
pointed out by Harding and Van Wyck”, but urobilinuria as an
index of liver damage in pregnancy has been criticized by
Huwer.'’ The patients referred to in the present paper were
investigated not only from the standpoint of their ability to ex-
crete intravenously injected bilirubin, but the urobilinogen con-
tent of the urine was estimated and the icterus index and the
Van den Bergh test on the blood serum were carried out as well.
Although the results of these are not included in this report, it
may be noted that while the amount of urobilinogen in the urine
tended to be somewhat greater in the toxic cases with normal
kidney functions (hepatic [ ?] toxaemia), a relation could not be
established between the urinary urobilinogen, the icterus index,
the results of the Van den Bergh test and the degree of retention
of injected bilirubin.

The question of increased intra-abdominal pressure as a factor
in the causation of delayed excretion of bilirubin in pregnancy
deserves some consideration. Paramore* has drawn attention to
the possible significance of a raised intra-abdeminal pressure dur-
ing the later stages of pregnancy in the production of hepatic
lesions and eclampsia. His views have been supported, but not
wholly substantiated, by the experimental work of Theobald.**
If increased pressure within the abdomen is a factor of importance

359

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JOURNAL OF OBSTETRICS AND GYNAECOLOGY

in causing mechanical obstruction to the outflow of bile from the
liver or in causing damage to the liver parenchyma leading to an
intra-hepatic obstruction to the elimination of bile pigment, the
greatest amount of retention should be expected to occur during
the second part of pregnancy when the pressure is greatest, more
especially in primigravidae, in whom the abdominal wall offers
the maximum amount of resistance. Introducing these delibera-
tions into the analysis of the above results, it is observed that
there is a definite tendency for a more marked retention of in-
jected bilirubin during the second half of pregnancy than during
the first half, but the numbers of primigravidae and multiparae
showing pathological retention are about equal. A correlation
could not be established between the height of the uterus or the
girth of the abdomen and the degree of bilirubin retention. It
would seem, therefore, that the problem of the relation of in-
creased intra-abdominal pressure to the results of the bilirubin
excretion test is unsolved at present. Certain relevant features
are presented by Case No. 15 (Table IV). This patient, a primi-
gravida aged 37, was admitted to the hospital with a diagnosis
of toxaemia of pregnancy of undetermined type. The abdomen
was remarkably distended. The bilirubin excretion test showed
only 4 per cent retention of the injected pigment after four hours.
In view of this normal result, together with the existence of hyper-
tension and the presence of marked albuminuria and cylindruria,
the case was classed as one of nephritic toxaemia. Opportunity
was not afforded for further investigation of her kidney functions
prior to her delivery of twins by Caesarian section.

SUMMARY.

The investigation of liver function by means of the bilirubin
excretion test of von Bergmann in pregnancy and its complica-
tions,.as described in this paper, permits the following inferences :

1. During the first half of normal pregnancy the liver function,
as determined by the bilirubin excretion test, is unimpaired, but
during the second half of normal pregnancy, evidence of dis-
turbed function can be demonstrated in at least 30 per cent of
cases.

2. The cause of the impaired excretory power of the liver
during the later stages of normal pregnancy is undetermined, but
the fact of its existence renders the interpretation of hepatic
efficiency tests in abnormal cases difficult.

3. Toxic patients, with signs of renal insufficiency, tend. to
show less retention of injected bilirubin than those with normal

360

5,
4

BILIRUBIN EXCRETION TEST

kidney functions. Thus, to some extent at least, it is possible
to differentiate the toxaemias of pregnancy into nephritic and
hepatic types. So far as the bilirubin excretion test is concerned,
there is not sufficient difference between the findings in toxic
patients and the results obtained in normal women during the
later months of pregnancy to be of practical significance. In cer-
tain instances, however, especially during the early stages of
pregnancy or in cases of extreme toxaemia, the test may supply
information of clinical importance.

4. That the impairment of liver function which occurs during
pregnancy, both normal and abnormal, is of a temporary nature
is indicated by the tendency for the results of the bilirubin excre-
tion test to return to normal following termination of the preg-
nancy.

5. Owing to its limited usefulness and the technical difficul-
ties involved, the bilirubin excretion test is unlikely to become
popular as a routine procedure in the practice of obstetrics.

The authors wish to express their grateful appreciation to Miss
Geraldine Webster, B.A., B.Sc., Reg. N., and to Mr. E. D.
Carpenter, for valuable technical assistance during the conduct
of this investigation.

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JOURNAL OF OBSTETRICS AND GYNAECOLOGY

TaBLe I

Non-pregnant Control Series.

No. of Retention of bilirubin

Case Age Preg- (percent)
No. (years) nancies hr. 2hrs. 4hrs. Diagnosis.

I 12 Chr, intestinal
obstruction
8 Peri-tonsillar Convalescent

abscess

Appendicitis 12 days post-

operative

Dysmenorrhoea

Normal

Backache Cause undeter-

mined

Diabetes
mellitus

Bronchial
asthma

Alevolar abs- Convalescent
cess

Parovarian cyst 12 days post-
Chr. appendi- operative
citis

Normal
Mild secondary
anaemia
Normal
Neurosis. Peptic
ulcer?
Chronic
arthritis
Normal
Normal
Normal
Cystocele
Psychasthenia

,
Remarks

12 39 72 10 2

13 28 62 13 5

= 14 33 48 8 I

15 24 89 19

2 16 18 oO 47 9 3

eee 17 30 o 59 13 7

18 25 52 7

19-23 49 TO

20 (35 4 44 8 4

21 32 7 36

36 2

BILIRUBIN EXCRETION TEST

TaBLe IT
Normal Pregnancy (First Half of Gestation).

Systolic
Period of | Blood Retention of Bilirubin

Age Gestation Pressure Albumin- (per cent)

(years) Para (months) (mm.) uria shr. 2hrs. 4hrs

116 +
114
140
110
128
130
120

118
?

20 I
21
40
30
32
23
17
18
36
34

108
?

Average -

III
Normal Pregnancy (Second Half of Gestation).

Systolic
Period of Blood Retention of Bilirubin

Case Age Gestation Pressure Albumin- (percent)
(years) Para (months) (mm.) uria 2hrs. 4 hrs
9 102
6 110
8 120
118
125
128
124
114
124
IIo
112
118
126
128

14
4
Continued

HH ON HWW NW
ON

363

Case

12 2
14 40 9 3 x

17 D 38 6 Oo

43 54 7

53 p 63 15 8 2

58 13 7
69 55 13 7 y
75 | o 62 14 14

78 61 II 7

79 a o 49 13 8 a

80 trace 60 19 2 =

JOURNAL OF OBSTETRICS AND GYNAECOLOGY

TasLe III (Continued).

Systolic
Period of Blood Retention of Bilirubin

Gestation Pressure Albumin- (per cent)
(years) Para (months) (mm.) uria 2hrs. 4 hrs

19
17
23
260
24
24
23
32
26
30
26
18
22

127
115
130
125
130
120
104
130
105
115
130
125
122
128
140

OM BNO A OW

122
126
120
126
122
130
125
130
126
IIo
135
125
128
22 118
29 128
32 6 126

Average

23
22
30
28
25
23
25
28
27
19
44
18
22

N w
ONO Oh DOH O

N
NN OHW

1
I
2
I
I
I
3
4
3
3
4
I
2
I
20 2 | 126
2
I
2
I
I
I
2
I
4
I
4
3
7

33 st I
35 oO 64 6 16
36 trace 37 6

44 55 17

46 oO 41

48 39 15

49 Oo 49 10

5 56 30 12

59 35 4

poe 61 trace 67 51

62 8

64 oO 42 19

7 54 8

ges trace 51 21

72 83 30

oe 73 trace 60 12

o 61 13

BILIRUBIN EXCRETION TEST

TaBLe IV
Toxic Pregnancy. Cases with Renal Insufficiency (Nephritic Group.)

Systolic
Period of | Blood Retention of Bilirubin
Case Age Gestation Pressure Albumin- (per cent)
(years) Para (months) (mm.) uria 4hrs

29 245 ++++

36 th
37 10 ++++
40 160 +

23 I 160 ++++
32 2 137 re
| 157

39 170

28 145

NWN OF O

|
|
|

Toxic Pregnancy. Cases Without Renal Insufficiency (Hepatic { 2? | Group).

Systolic
Period of | Blood Retention of Bilirubin
Case Age Gestation Pressure Albumin- (per cent) .
No. (years) Para (months) (mm.) uria

22 129 ++
29 130 ++
21 138
34 160
41 140
24 155
40 140
20 158
20 210
27 195
22

nv Oo

24
39

=
I 51 21 =
4 27
15 32 7
17 52 13 aay
34 27 3 =
42 58 14
47 58 15
63 36 6 “gs
77 66 15 ig
Average - - - 45 10
TaBLeE V
63 30 19
3 51 15 12
7 52 30 15 oa
8 63 22 16 e
10 30 7
19 ) 59 15 10
20 5 3 6 2 E
27 58 21
3! . 34
52 40 24
45 33 | 14 120 trace 66 22 17 &
57 7% 162 46 15 10
66 | 9 169 + 89 37 15 i
Average - - 55 21 14
365
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JOURNAL OF OBSTETRICS AND GYNAECOLOGY

TABLE VI.
Comparison of the Results of the Bilirubin Excretion Test Before and After
Parturition (Non-toxic Cases).

Retention of Bilirubin

Case (per cent)
No. Time hrs:
13 (a) 2 months ante-partum 73 42— 33
(b) 12 days post-partum 87 48 26
16 (a) 9 days ante-partum 53 18 11
(b) 10 days post-partum 54 12 9
22 (a) 4 weeks ante-partum 79 33 19
(b) 12 days post-partum 37 te) oO
23 (a) 3 months ante-partum 58 18 13
(6) 11 days post-partum 59 10 2
25 (a) 2 months ant2-partum 31 28 TO.
(b) 10 days post-partum 82 25 20
29 (a) 3 days ante-partum 69 34 14
(b) 10 days post-partum 58 30 om)
35 (a) 7 weeks ante-partum 64 6 16
(b) 11 days post-partum 41 oO 0)
37 (a) 10 weeks ante-partum 36 17 9
(b) 17 days post-partum 55 15 6
40 (a) 4 weeks ante-partum 36 Ay 4 9
(b) 13 days post-partum 45 15 6
44 (a) 10 weeks ante-partum 55 17 18
(b) 12 days post-partum 56 16 I
46 (a) 12 weeks ante-partum 41 7 15
(b) 12 days post-partum 36 5 4
51 (a) 8 weeks ante-partum 44 20 8
(b) 11 days post-partum 60 13 4
52 (a) 8 weeks ante-partum 56 30 12
(b) 24 days post-partum 60 27 12
54 (a) 5 weeks ante-partum 56 II wo
(b) 21 days post-partum 66 15 3
Average, ante-partum - - 54 21 14
Average, post-partum - - - - 57 16 7
366

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BILIRUBIN EXCRETION TEST

TaB_Le VII

Comparison of the Results of the Bilirubin Excretion Test Before and After

Parturition (Toxic Cases).

Retention of Bilirubin

Case (per cent)
No. Time 2hr. 2hrs. 4 hres.

2 (a) 4 weeks ante-partum 63 30 19
(b) 13 days post-partum 53 II fe)

3 (a) 5 months ante-partum 51 15 12
(b) 13 days post-partum 60 18 12

7 (a) 6 months ante-partum 52 30 15
(b) 11 days post-partum 56 24 7

8 (a) 3 weeks ante-partum 63 22 16
(b) 11 days post-partum 41 8 o

28 (a) 5 weeks ante-partum 39 9 4
(b) 1 day ante-partum 53 38 54

41 (a) 6 weeks ante-partum 52 40 24
(b) 16 days post-partum 51 25 12

45 (a) 6 weeks gestation 66 22 17
(b) 9 days post-abortion 34 10 9

47 (a) 3 weeks ante-partum 58 15 7
(b) 14 days post-partum 69 9 fo)

Average, ante-partum - 55 25

Average, post-partum - - - 49 14 5

. Stander, J. H. ‘‘The Toxaemias of Pregnancy,’

REFERENCES.

. Cruickshank, J. N., J. Hewitt and K, L. Couper. ‘‘The Toxaemias of

Pregnancy, Clinical and Biochemical Study.’’ Med. Research Council,
Spec. Rep. Series, 1927, No. 117, p. 30.

. De Wesselow, O.L.V., and J. M. Wyatt. ‘‘Modern Views on the Toxae-

mias of Pregnancy,’’ Constable & Co., London, 1924.
’ Medicine Monographs,
1929, vol. xv, p. 92. Williams & Wilkins Co., Baltimore.

. King, E. L. “Liver Function Tests in Toxaemias of Pregnancy.”’
South. Med. Journ., 1930,. xxiii, 1930.
. Solomons, B. ‘‘Some Phases of the Toxaemias of Pregnancy,’’ Amer.

Journ. Obstet. and Gynecol., 1933, Xxv, 172.

. Kaufmann, C. ‘‘Uber die Schwangerschaftsleber.’’ Zeitschr. f. Geburtsh.
u. Gynidkol., 1931, xcix, 582.

. Krebs, O. S., and W. J. Dieckmann. ‘‘Rosenthal Liver Function Test in
Obstetrics.’” Amer. Journ. Obstet. and Gynecol., 1924, vii, 89.

. Siegel, I. A. ‘Liver Function in Pregnancy,’’ Amer. Journ. Obstet. and

367

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3
6
8
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JOURNAL OF OBSTETRICS AND GYNAECOLOGY

Gynecol., 1927, Xiv, 300.

. Smith, J. A. ‘‘Phenoltetrachlorphthalein Test of Liver Function in
Toxaemias of Pregnancy.’’ Amer. Journ. Obstet. and Gynecol., 1924,
viii, 298.

. Huwer, G. ‘‘Der Blutfarbstoffwechsel in der Graviditat, zugleich eis
Beitrag zur Frage der Leberfunktion in der Schwangerschaft.’’ Zeitschr.
f. Geburtsh. u. Gynidkol., 1933, cvi, 324.

. Von Bergmann, O. ‘‘Zur Functionellen Pathologie der Leber,’’ Klin.
Wochenschr., 1927, vi, 776.

. Eilbott, W. ‘‘Funktionspriifung der Leber mittels Bilirubin Belastung.”’
Zeitschr. f. Klin. Med., 1927, cvi, 529.

. Harrop, G. A., and E. S. G, Barron. ‘‘The Excretion of Intravenously
Injected Bilirubin as a Test of Liver Function.’’ Journ. Clin. Invest.,
1931, ix, 577-

. Kaufmann, C. ‘‘Uber die Schwangerschaftsumtellung der Leberfunktion,”’
Klin. Wochenschr., 1932, xi, 493.

. Stroebe, F. ‘‘Latente Hepatopathie nach Schwangerschaftstoxikose,”’
Klin. Wochenschr., 1932, xi, 495.

. Hofbauer, J. ‘‘Hepatopathia Gravidarum und die Pathogenese der
Eklampsie,’’ Zentralbl. f. Gyniikol., 1933, i, 35-

. Soffer, L. J. ‘‘Bilirubin Excretion as a Test for Liver Function during
Pregnancy,’’ Johns Hopkins Hosp. Bull., 1933, lii, 365.

. Watson, E. M. ‘‘The Bilirubin Excretion Test as an Index of Liver
Function.’”’ Univer. West. Ont. Med. Journ., 1933, iii, 75.

. Ernst, Z., and J. Forster. ‘‘Uber die Bestimmung des Blutbilirubins,’’
Klin. Wochenschr., 1924, iii, 2,386.

. Williams, J. Whitridge. ‘‘Obstetrics.’’ Appleton & Co., New York,
1930, p. 635.

. King, E. L. ‘‘Liver Function Tests in the Toxaemias of Pregnancy,’’
Amer. Journ. Obstet. and Gynecol., 1926, xii, 577.

. Mackenzie, L. L. ‘‘The Toxaemias of Pregnancy with Special Reference
to Liver Function,’’ Amer. Journ. Obstet. and Gynecol., 1932, Xxiv, 233.

. Harding, V. H., and H. B. Van Wyck. ‘‘Urobilinuria in Vomiting of
Pregnancy,’’ Journ. Obstet. and Gynaecol. Brit. Emp., 1929, xxxvi, 561.

. Paramore, R. H. ‘‘The Hepatic Lesions,’’ Journ. Obstet. and Gynaecol.
Brit. Emp., 1932, Xxxix, 777.

. Theobald, G. W. ‘‘The Hepatic Lesions Associated with Eclampsia and
those Caused by Raising the Intra-abdominal Pressure,’’ Journ. Path.
and Bact., 1932, xxxv, 843.

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Fic. 4.
Showing a comparison of the results obtained with the bilirubin excretion
test before and after delivery in patients who showed toxic manifestations
during pregnancy.

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en

on.

The Biology of the Vagina in the Human Subject.
BY
ROBERT CRUICKSHANK, M.D. (Aberdeen), D.P.H.

Lecturer in Bacteriology, University of Glasgow; Bacteriologist
to Glasgow Royal Infirmary.

AND
ALBERT SHARMAN, M.D., B.Sc. (Glasgow), M.C.O.G.

Assistant Surgeon, Royal Samaritan Hospital for Women,
Glasgow.
(From the Pathological Institute of the University and Royal Infirmary,
and the Royal Samaritan Hospital for Women, Glasgow.)

ParT III. VAGINAL DISCHARGE OF NON-INFECTIVE ORIGIN.

I. INTRODUCTON.
2. METHODS OF EXAMINATION.
3. VIRGINAL LEUCORRHOEA.

Definition.

The Normal Secretions.

The Aetiology of Leucorrhoea.

Rare Causes of Virginal Leucorrhoea.

Non-infective Leucorrhoea.

Infective Leucorrhoea.

The Treatment of Leucorrhoea.
4. NON-INFECTIVE LEUCORRHOEA IN PREGNANCY.
5. Discussion.
6. SUMMARY.

1. INTRODUCTION.

THis part of our investigations is concerned mainly with
leucorrhoea in the virgin. In a survey of a series of
hospital cases of virginal leucorrhoea it was obvious that the
causation, or mechanism of production, was unknown in a large
proportion, while the treatment was frequently irrational and un-
satisfactory. For example, the case-records and after-histories
of the 76 patients admitted during the five-year period, 1924 to
1929, to the Royal Samaritan Hospital for Women, Glasgow, for
treatment of the condition were investigated. Their subsequent
histories showed that only 50 per cent of them had benefited
from -hospital treatment. Twenty-three of the 76 patients had

369

JOURNAL OF OBSTETRICS AND GYNAECOLOGY

not any detectable abnormality in the genital tract, and in 13 of
these the leucorrhoea was not affected by treatment. The treat-
ment varied, dilatation and curettage, cauterization of the cervix
either alone or in conjunction with curettage, or systematic
painting and douching of the vagina with an antiseptic, or the
patients were simply examined under anaesthesia.

A clinical survey of the cases did not help in elucidating the
problem. It was, therefore, decided to institute a more thorough
clinical investigation combined with a complete laboratory
examination. Mainly as a result of the latter, we were able to
divide cases of virginal leucorrhoea into two main groups, which
we called infective and non-infective. It is not our intention to
deal here with the former except by way of comparison. On the
other hand non-infective virginal leucorrhoea presents phe-
nomena bearing on our studies on the vaginal flora and secretion
in the normal individual.

2. METHODS OF EXAMINATION.

A careful clinical examination was made of all cases of
virginal leucorrhoea. Among the points investigated were the
age, sex-history, pelvic examination under anaesthesia, naked-
eye character of the vaginal discharge, radiography of the sella
turcica, and the basal metabolic-rate and sugar-metabolism.
Laboratory examination included microscopic study of a fresh
drop of the vaginal secretion in saline, estimation of the H-ion
concentration by means of the capillator indicator (British Drug
Houses) and repeated bacteriological examinations of smears and
cultures from vagina, cervical canal and uterine cavity. In a
limited number of patients, small fragments of vaginal mucosa
were removed and examined for glycogen, in some cases
repeatedly. The urine of some of the patients was examined for
the presence of anterior pituitary hormone and the ovarian fol-
licular hormone, oestrin. In the pregnant women a full examina-
tion, involving smears, cultures and estimation of the hydrogen-ion
concentration was made.

3. VIRGINAL LEUCORRHOEA.

Definition. In the clinical study of virginal leucorrhoea, we
concerned ourselves only with patients in whom on examination
the hymen was apparently intact and by whom sexual inter-
course was emphatically denied. However, it is appreciated
that persistence of the hymen need not unequivocally point to
the existence of virginity. We regarded leucorrhoea as that
degree of discharge other than blood-stained, sufficient to soil

370

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BIOLOGY OF THE VAGINA

the clothes, or necessitate the use of a sanitary napkin, and con-
sidered by the patient as an appreciable departure from her
normal state. The very mild degrees of excessive discharge,
pre-menstrually, or temporarily, during conditions of depressed
general health, are not considered.

The normal secretions. An excessive discharge from the
vagina may reasonably arise from any one of three sources—
vagina, cervix or uterus—and it is necessary to determine which
source is responsible for the leucorrhoea and, if possible, its
cause or causes. In order to appreciate fully the pathogenesis
of excessive discharge from the female genital tract, it is
essential that the histology of the tract, more particularly that of
the lining membranes, should be clearly understood. The two
Miillerian ducts of the embryo, lined by columnar epithelium,
fuse to form the Fallopian tubes, uterus, cervix and vagina of
the adult. The epithelium in the Fallopian tubes becomes con-
verted to ciliated columnar epithelium, in the body of the uterus
to low columnar epithelium, in the cervix to a non-ciliated high
columnar epithelium, and in the vagina to squamous epithelium.
The change in vaginal epithelium is not due to a conversion of
the original columnar epithelium, but to a replacement of it by
squamous epithelium growing from below upwards from the
region of the uro-genital membrane. Simple tubular glands
appear in the endometrium and compound or racemose
glands in the mucus-secreting cervical epithelium; the vaginal
mucosa does not contain any glands and is lined by squamous
epithelium in the same way as the vaginal aspect of the cervix
Fischel,' however, has shown that in 36 per cent of the newborn,
the portio is covered with a single layer of cylindrical epithelium,
with frequent persistence of cervical glands (congenital erosion).
In later life, if the replacing squamous epithelium desquamates,
the epithelium from persistent foetal glands covers the denuded
surface with a cylindrical layer.

The uterus, cervix and vagina each have their own character-
istics, normal secretion. The tubular glands of the endometrium
are the source of a small quantity of secretion in the normal
uterus. Fritsch,’ in 1885, had mentioned this, but made the
mistake of assuming that the normal vaginal secretion consisted
mainly of secretion from the uterus and Bartholin’s glands.
Whitchouse* mentioned the rare condition of white menstrua-
tion, in which a white discharge consisting of the secretion of
the uterine glands occurs without haemorrhage from the uterus;

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JOURNAL OF OBSTETRICS AND GYNAECOLOGY

the sexual organs did not present any apparent anatomical
abnormality. The secretion from the racemose glands of the
cervix is thick, mucoid, viscous and alkaline, and forms the
typical cervical secretion which, in the non-infected cervix, is
small in amount. The vaginal secretion is thick, white, caseous
and highly acid in reaction. The healthy female subject is
usually not aware of these natural secretions.

The aetiology of leucorrhoea. Leucorrhoea is a common
complaint, and is most frequent in married women. Davis"
found, in a review of 1,000 histories of gynaecological and
obstetrical patients, that about 33 per cent had leucorrhoea.
The cause of the discharge in these cases was usually obvious,
in most instances being due to cervical infection following child-
birth, abortion or gonorrhoea. Less commonly vaginitis, due
often to trichomonas vaginalis, was the cause of the leucorrhoea.
In virgins, however, the complaint of leucorrhoea is uncommon,
although its incidence cannot, for obvious reasons, be accurately
determined. Most gynaecologists have encountered cases of
virginal leucorrhoea and have had difficulty in understanding its
pathogenesis, as well as frequent failures from their therapeutic
efforts. It is usually stated that constitutional disorders may be
responsible for excessive discharge in virgins, due to a low-grade
infection of the cervix. Pelvic congestion and constipation have
also been blamed as aetiological factors. Payne’ claimed that
infection of the nulliparous cervix, the canal of which is normally
filled with a thick tenacious mucus acting as a barrier against
contamination from the vagina, generally began as an endo-
cervicitis and was usually of an ascending type. In patients
suffering from endocervicitis, investigated by Burns,‘ five were
stated to have shown certain stigmata usually associated with
masturbation. He believed that sexual excitation is accom-
panied by congestion of the pelvic organs and, if frequently
indulged in, brings about a condition approaching chronic con-
gestion, which induces oversecretion of the cervical glands, in
other words leucorrhoea. The external genital organs become
bathed in this discharge; the bacteria which are always present
spread up to the cervix and the glands become infected. Once the
glands are infected, the presence of the organisms and _ their
toxins maintain the oversecretion, and so the condition of endo-
cervicitis is established. Kidd and Simpson’ also stated that,
under conditions of sexual excitement, an almost instantaneous
pouring-out of secretion occurs from the glands of the vulva and

372

BIOLOGY OF THE VAGINA

cervix for purposes of lubrication, and they claimed that the
leucorrhoea of young girls may be brought about by an un-
natural stimulation of the parts. Our own findings do not suggest
that virginal leucorrhoea is commonly produced in the way sug-
gested by these authors. ;

Rare causes of virginal leucorrhoea. Before the results of
our investigation during a period of three years, of some 40 cases,
are detailed, it is advisable that certain rare pathological con-
ditions which may give rise to leucorrhoea in the virgin should
first be mentioned.

In virgins tuberculosis of the uterus or vagina may cause
leucorrhoea. In the uterus it is rarely primary and most fre-
quently direct infection from the Fallopian tubes occurs, while
less than 20 primary cases of cervical tuberculosis have been
recorded (Douglass and Ridlon*). A tuberculous perineal abscess,
opening into the vagina with the hymen intact, may occur.
Carcinoma of the vulva usually occurs in women more than 50
years of age, but Kinoshita’ observed it in a virgin of 15 years.
A review of the in-patient records of the Royal Samaritan Hos-
pitai for Women, Glasgow, over a period of 10 years (involving
over 23,000 admissions), showed that the youngest virginal patient
in the series suffering from vulval cancer was aged 25 years.
Carcinoma of the hymen in a virgin of 57 years was described by
Frankl.'® Cancer of the vagina is rare in nulliparae but has been
encountered in virgins. A thin, watery, irritating discharge is
usually the earliest symptom and may be of considerable dura-
tion. Many isolated cases of cervical carcinoma in young women
have been recorded. Intermediate between inflammatory and
benign and malignant neoplasms of the vagina is the condition
reported by Plaut"’ under the designation of ‘‘diffuse adeno-
matosis’’ of the vagina. The entire vaginal canal was covered by
a purple-red eroded mucosa. A similar condition was described
by Bonney and Glendinning” as adenomatosis vaginae.

With the exception of the Trichomonas vaginalis, vaginal
parasites as a cause of irritation and discharge are not of much
importance. Oxyuris vermicularis may be found, especially in
the vagina of neglected infants (Chandler'*). Amoeba _ uro-
genitalis, ascaris, echinococcus and filaria Bancrofti rarely occur.
Membranous vaginitis is a rare condition resembling membran-
ous enteritis and membranous dysmenorrhoea, superficial
moulds being repeatedly cast off (Gellhorn’* and Kerwin"’).
Vaginal ulcers are stated to result from any causes which

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JOURNAL OF OBSTETRICS AND GYNAECOLOGY

The aetiology of leucorrhoea. Leucorrhoea is a common
complaint, and is most frequent in married women. Davis‘
found, in a review of 1,000 histories of gynaecological and
obstetrical patients, that about 33 per cent had leucorrhoea.
The cause of the discharge in these cases was usually obvious,
in most instances being due to cervical infection following child-
birth, abortion or gonorrhoea. Less commonly vaginitis, due
often to trichomonas vaginalis, was the cause of the leucorrhoea.
In virgins, however, the complaint of leucorrhoea is uncommon,
although its incidence cannot, for obvious reasons, be accurately
determined. Most gynaecologists have encountered cases of
virginal leucorrhoea and have had difficulty in understanding its
pathogenesis, as well as frequent failures from their therapeutic
efforts. It is usually stated that constitutional disorders may be
responsible for excessive discharge in virgins, due to a low-grade
infection of the cervix. Pelvic congestion and constipation have
also been blamed as aetiological factors. Payne’ claimed that
infection of the nulliparous cervix, the canal of which is normally
filled with a thick tenacious: mucus acting as a barrier against
contamination from the vagina, generally began as an endo-
cervicitis and was usually of an ascending type. In patients
suffering from endocervicitis, investigated by Burns,‘ five were
stated to have shown certain stigmata usually assoeiated with
masturbation. He believed that sexual excitation is accom-
panied by congestion of the pelvic organs and, if frequently
indulged in, brings about a condition approaching chronic con-
gestion, which induces oversecretion of the cervical glands, in
other words leucorrhoea. The external genital organs become
bathed in this discharge; the bacteria which are always present
spread up to the cervix and the glands become infected. Once the
glands are infected, the presence of the organisms and _ their
toxins maintain the oversecretion, and so the condition of endo-
cervicitis is established. Kidd and Simpson’ also stated that,
under conditions of sexual excitement, an almost instantaneous
pouring-out of secretion occurs from the glands of the vulva and

372

—
ie,
cer

BIOLOGY OF THE VAGINA

Rare causes of virginal leucorrhoea. Betore the results of
our investigation during a period of three years, of some 40 cases,
are detailed, it is advisable that certain rare pathological con-
ditions which may give rise to leucorrhoea in the virgin should
first be mentioned.

In virgins tuberculosis of the uterus or vagina may cause
leucorrhoea. In the uterus it is rarely primary and most fre-
quently direct infection from the Fallopian tubes occurs, while
less than 20 primary cases of cervical tuberculosis have been
recorded (Douglass and Ridlon*). A tuberculous perineal abscess,
opening into the vagina with the hymen intact, may occur.
Carcinoma of the vulva usually occurs in women more than 50
years of age, but Kinoshita’ observed it in a virgin of 15 years.
A review of the in-patient records of the Royal Samaritan Hos-
pitai for Women, Glasgow, over a period of 10 years (involving
over 23,000 admissions), showed that the youngest virginal patient
in the series suffering from vulval cancer was aged 25 years.
Carcinoma of the hymen in a virgin of 57 years was described by
Frankl.’ Cancer of the vagina is rare in nulliparae but has been
encountered in virgins. A thin, watery, irritating discharge is
usually the earliest symptom and may be of considerable dura-
tion. Many isolated cases of cervical carcinoma in young women
have been recorded. Intermediate between inflammatory and
benign and malignant neoplasms of the vagina is the condition
reported by Plaut'' under the designation of ‘‘diffuse adeno-
matosis’’ of the vagina. The entire vaginal canal was covered by
a purple-red eroded mucosa. A similar condition was described
by Bonney and Glendinning” as adenomatosis vaginae.

With the exception of the Trichomonas vaginalis, vaginal
parasites as a cause of irritation and discharge are not of much
importance. Oxyuris vermicularis may be found, especially in
the vagina of neglected infants (Chandler'’). Amoeba uro-
genitalis, ascaris, echinococcus and filaria Bancrofti rarely occur.
Membranous vaginitis is a rare condition resembling membran-
ous enteritis and membranous dysmenorrhoea, — superficial
moulds being repeatedly cast off (Gellhorn’* and Kerwin"’).
Vaginal ulcers are stated to result from any causes which

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>,

JOURNAL OF OBSTETRICS AND GYNAECOLOGY

produce localized defects in the epithelial covering of the wall.
These ulcers may be encountered in severe cases of uraemia
(Eichhorst'*). The ulcus rotundum, which appears as a single
or multiple punched-out lesion, may be partly due to arterio-
sclerosis, but infection later undoubtedly enters into the process
(Frank,'’ Fluhmann'‘). Condylomata acuminata, although
most commonly associated with gonorrhoea may not be venereal
in origin, since they result also from non-specific irritation, and
may be found in children and virgins (Smith'’). Infectious
diseases such as typhoid fever, scarlet fever and diphtheria are
occasionally complicated by vaginitis. True diphtheritic vagin-
itis, of a necrotic type, and even of a gangrenous type, may be
encountered.

Submucous fibroids and polypi of the uterine body or cervix
may be responsible for discharge per vaginam in virgins.
Erosion of the cervix is, in our experience, only occasionally the
cause of leucorrhoea in a virgin. Frequently erosions are seen
in virgins who are operated on for other symptoms, but who
have never complained of excessive discharge. “ Again we have
repeatedly seen cases, which have been followed up, in which an
erosion, the presumed cause of leucorrhoea, has been cauterized
or excised without any appreciable improvement in the dis-
charge, although subsequent examination has not revealed any
evidence of the original erosion. It is to be noted, too, that in
those cases of the series in which it was done, cervical culture
proved almost invariably sterile.

The role of the cervix in the production of a discharge of
doubtful origin may be investigated, by estimating the reaction
of the latter. The cervical reaction is constantly and definitely
alkaline, and, according to Meaker and Glaser,”’ ranges from
pH 8.0 to pH 9.0. Its fH is above 8.5 in about 80 per cent of
cases and is not notably influenced by age, parity or endo-
cervicitis, notwithstanding the fact that in the last-named con-
dition there may be a great increase of secretion which may be
mucoid, muco-purulent or blood-tinged and contain pus-cells,
lymphocytes, epithelium and bacteria. These facts are further
proof that the alkaline discharge of cervical origin is readily
differentiated from the highly acid vaginal one; the former can-
not largely contribute to the leucorrhoea, the reaction of which
is, for example, PH 4.4. Infection of the uterine cavity, as a
source of leucorrhoea, is extremely rare. Curtis** conclusively
proved this by histological and bacteriological examinations of
the endometrium in a large number of cases.

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BIOLOGY OF THE VAGINA

Non-infective virginal leucorrhoea. The result of our clinical
and laboratory study of virginal leucorrhoea may now be des-
cribed. Each patient was examined in detail from both the
clinical and laboratory standpoints, but it is obviously un-
desirable that a mere series of descriptions of each of these cases
should be given. The main features investigated appear in the
the description of the results. While we investigated more than
40 cases, in some of them observations were not made over a
sufficiently long period of time on account of patients defaulting,
or the laboratory findings were incomplete, and so the described
series is restricted to 35 cases. It is divided into two main
categories: (1) non-infective and (2) infective. It is with the
former type that we are here concerned. Among the non-
infective cases there was a group in which hormonal disturbance
was strongly suggested, either by the individual’s general condi-
tion or by gross menstrual malfunction such as prolonged or
almost complete amenorrhoea. In other cases there was not any
obvious evidence of endocrine imbalance and distinctive clinical
features were not noted. The patients included in the hormonal
group were frequently excessively stout, sometimes complained of
pain in one or other side of the abdomen and had lengthy spells
of intermittent amenorrhoea during which leucorrhoea was often
increased. Spontaneous remission of the discharge tended to
occur at intervals. The average age of all patients at the onset
of the leucorrhoea was Ig years, as contrasted with the infective
group, in which the average age was 24 years. Sometimes the
complaint dated from puberty, and in three of the series, excessive
discharge was noted before menstruation first commenced. All
predisposing or exciting causal factors were absent. Anaemia,
debility and constipation were not common clinical features of
the cases. In an attempt to find evidence of endocrine mal-
function skiagrams of the sella turcica, blood-sugar curves, basal
metabolic rates and the Zondek-Aschheim test for pregnancy were
made in a number of cases. The radiologist reported that there
was marked diminution in the size of the sella turcica in two of five
cases in which skiagraphs of the skull were taken. In one there
was slight diminution in size, one was unsatisfactory, and the fifth
was normal. The visual fields in these cases were normal. Blood-
sugar curves were estimated in four cases by Dr. D. P. Cuth-
bertson and were within normal limits, with the exception of one
case in which the figure rose above 0.2 grammes per 100 cubic
centimetres of blood. In this patient, the basal metabolic rate
was - 20, there was slight glycosuria and it was thought that she

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was a potential diabetic. Basal metabolic estimations in three
other cases were normal (D. P. Cuthbertson). Zondek-Aschheim
tests were uniformly negative, but excess of oestrin in the urine
was found in four cases out of five.

Inflammatory or other lesions were not discovered on
vaginal examination. Apart from the obviously excessive
character of the secretion, local evidence of abnormality was
absent, except that the uterus was occasionally found to be much
underdeveloped or the endometrium showed, on_ histological
examination, glandular hyperplasia. In the cases in which
portions of vaginal epithelium were excised, histological exam-
ination showed them to be deep, many-layered and florid. When
stained with Best’s carmine, glycogen was abundantly present.
This was noted even when the patient was about the age of
puberty and menstruation had not yet commenced.

The vaginal discharge was thick, white, inspissated or caseous,
and non-irritating. It was not sutticiently tluid to pour forth out
of the vagina as is usually the case with a purulent discharge.
It was frequently increased premenstrually. Bacteriological ex-
amination revealed information as follows: Vaginal smears
showed a grade I flora—abundant B. vagine (Déderlein), epi-
thelial cells and no pus cells; vaginal culture on serum agar
gave a growth of B. vaginae (Déderlein), no growth, or a few
colonies of staphylococci; vaginal culture on Sabouraud’s medium,
for cultivation of yeasts, was sterile; cervical culture was gener-
ally sterile, but occasionally showed a few staphylococci, pro-
bably contaminants; intra-uterine culture (swab being passed
through a hollow, tubular, glass, cervical dilator) was invariably
sterile. The reaction of the secretion was highly acid, varying
from pH 4.2 to pH 4.7. The following brief clinical histories
exemplify some of the features of cases of the non-infective group :

Miss M.B., aged 23 years, was admitted to the Samaritan Hospital on
7th May, 1928, complaining of an excessive white discharge of about seven
years’ duration and of dysmenorrhoea of six months’ duration. On
examination she proved to be in good general health but excessively stout,
weighing nearly 13 stones. Under anaesthesia the hymen was found intact
and the vagina, cervix and pelvic organs were not abnormal. The
cervix was dilated and the uterus curetted. The source of the leucor-
thoea was not apparent. The patient reported 20 months later, when her
menstrual pains were considerably improved, but her discharge undimin-
ished. Radiostoleum (a preparation of vitamins A and D) was prescribed
for two months, but at the end of this time there was not any appreciable
improvement. Fifteen months later she reported that discharge was still
troublesome and dysmenorrhoea had recurred. She had, during all this

376

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BIOLOGY OF THE VAGINA

time, received attention to her general health. She was then re-admitted to
hospital. Under anaesthesia, she was examined very carefully and signs of
infection in vagina and cervix were absent. The cervix was dilated for
purposes of investigation. Both cervical and uterine cultures proved sterile. A
vaginal smear showed a grade I flora and culture gave an almost pure growth
of Déderlein’s bacillus. The reaction of the discharge was highly acid—
pH 4.2. It was obvious that her leucorrhoea was of the non-infective type.
She was given emmenin (Collip’s placental hormone, kindly supplied to us
by Professor Collip) one drachm orally thrice daily for six weeks, without
any appreciable effect. It was then thought that irradiation of the ovaries,
with a dosage short of a castration one, might prove of value and this was
done at our request by Dr. Bruce McLean. After two months the patient
reported some improvement in her complaint, but also menstrual irregu-
larity. The improvement was not sustained and it was decided that the
risks of irradiation outweighed any possible advantages. Negative results
were obtained in the various lines of investigation mentioned previously
(basal metabolism, etc.), with the exception that radiography of the sella
turcica showed it to be markedly diminished in size. There was excess
of oestrin in the urine. Examination of the discharge again revealed a
grade I flora; the pH of the discharge was 4.4. Several ovarian
hormonal preparations were subsequently tried for eight months without any
outstanding success. She reported again in September, 1932, when she
stated that the discharge was not quite so profuse and troublesome.

Miss B., aged 13 years and nine months, attended the out-patient
department of the Samaritan Hospital, complaining of an excessive vaginal
discharge. Menstruation had not yet occurred. There was evidence of
puberty in slight development of the secondary sexual characters. Her own
doctor had mentioned the possiblity of the discharge being gonorrhoeal in
origin, and accordingly the patient’s mother was greatly alarmed. Clinical
examination revealed an intact hymen, no signs of infection but an obvious
leucorrhoea. Bacteriological examination of the discharge showed a pure
grade I flora, and the estimation of its reaction gave a pH of 4.6. The
condition was obviously of the non-infective type and treatment other than
that of a general medical nature was not suggested. At the end of six
months the patient reported that the discharge was less in amount.

A tendency to spontaneous remission of the leucorrhoea in
these cases was characteristic and frequently freedom from dis-
charge for intervals of several weeks occurred. The histories of
other typical patients in this group may now be briefly sum-
marized.

Miss M.D., aged 13 years and two months, complained of irregular
menstruation and _ leucorrhoea. Menstruation commenced when_ she
was 12% years old and occurred at fortnightly and monthly intervals
irregularly and was excessive in amount. Excessive vaginal discharge had
been complained of for about two years. On examination the hymen was
found intact and evidence of infection was absent. The discharge was
thick, white, had a pH of 4.2 and showed a typical grade I flora. She was
seen again about one year later, when it was stated that menstruation had

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JOURNAL OF OBSTETRICS AND GYNAECOLOGY

been regular for about six months and that almost coincidently leucorrhoea
had considerably improved. A vaginal smear showed a grade I flora.

Miss W.M., aged 14 years and seven months, was admitted to the
Samaritan Hospital on 5th March, 1932. She complained of excessive
vaginal discharge, of a little more than one year’s duration. Menstruation
had commenced one year before admission and had been regular and pain-
less. The patient was exceedingly well developed and in appearance could
easily have passed for 17 or 18 years old. The hymen was intact. Vaginal
smear showed a grade I flora and estimation of the reaction of the discharge
gave pH 4.4. A positive oestrin reaction was obtained from her urine.
There was slight diminution of the sella turcica. Local treatment was not
given. Two months later examination of the discharge gave the same
findings. Three months subsequently she reported that the discharge had
improved. Examination on this date again gave a similar result, and the
pH was now 4.6. One year later she reported that the discharge was much
improved.

Miss H.W., aged 24 years, complained of irregular menstruation and
constant leucorrhoea, each of one year’s duration. During the 12 months
immediately prior to her admission to the Samaritan Hospital on 11th
November, 1931, she had menstruated on three irregular occasions only.
She was small in stature but excessively stout, weighing over 13 stones.
There had been recently a rapid increase of weight. She was examined
under anaesthesia and vaginal, cervical and intra-uterine smears and
cultures made. A snipping of vaginal epithelium was removed. The vaginal
smear showed a grade I flora. The discharge gave pH 4.2. Excess of oestrin
was present at one examination of the urine. There was marked diminution
of the sella turcica. Local treatment was not given. She was seen at
intervals of three months and the discharge examined. Laboratory findings
were similar throughout. The discharge showed remissions in its profuse-
ness. When last seen in September 1933 she stated that menstruation was
tending to become more regular and the discharge to diminish. Throughout
the time of her attendance at hospital various endocrine preparations were
given to her, including thyroid and ovarian extracts. The response of her
symptoms to any one of these appeared to be inconstant.

Infective Virginal Leucorrhoea. The other category mentioned
for comparison was the infective one and in these cases the age
incidence tended to be higher. In this group, the majority of the
cases were infected with Trichomonas vaginalis, while one definite
case of yeast, or Monilia, vaginitis was encountered. Nine cases of
trichomonas infection in virgins were studied. As compared with
the non-infective group, the discharge was more watery, yellow,
finely frothy, occasionally blood-tinged and generally irritating.
The vulva and vagina frequently appeared to be inflamed. Diag-
nosis of the condition was made by fresh-drop examination of
the secretion when numerous motile trichomonas were seen. A
vaginal smear showed a grade III flora--an abundant and varied
bacterial flora and pus cells) and vaginal culture yielded a

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BIOLOGY OF THE VAGINA

variety of organisms, but not, as a rule, any Déderlein’s vaginal
bacilli. The reaction of the secretion varied from pH 4.9 to
pH 6.0. In the single case of monilia vaginitis encountered the
discharge was profuse and semi-purulent, causing considerable
irritation and extensive intertrigo. On fresh-drop examination
and smears, abundant monilia or yeast-like bodies were seen.
In only two cases of the series did it seem as if an erosion of
the cervix was the sole cause of leucorrhoea. A typical case of
the infective type of virginal leucorrhoea is as follows:

Miss R., aged 23 years, was admitted to the Royal Samaritan Hospital
on 9th August, 1929, complaining of a profuse, irritating discharge of three
years’ duration. Under anaesthesia the hymen was found to be intact and
pelvic abnormality was absent. The cervix was dilated and the uterus curet-
ted. She reported four months later that there was not any improvement.
Various attempts at douching were made and several ovarian preparations
were administered. She was re-admitted to hospital on 12th March, 1930.
The cervical canal was cauterized and the vagina douched thrice daily for
10 days. Vaginal smears showed a grade III flora. Her condition improved
for two months, but one month later she reported that the discharge was as
profuse as ever. Radiostoleum was exhibited for one month and there was
an apparent improvement which proved temporary. Fresh-drop examina-
tion of the yellow, finely frothy discharge was then made and revealed
abundant trichomonas vaginalis. Intensive local treatment against this
parasite was then carried out and the leucorrhoea improved considerably.

The laboratory findings in the two categories of virginal
leucorrhoea are summarized in the following table:

Non-infective (20 cases)

Secretion White, viscid, cheesy
Smear Grade I flora (epithelial
cells and Déderlein’s
vaginal bacillus)
Culture Déderlein’s bacillus
Reaction
Average pH 4.4 (4.2-4.7)

Infective (15 cases)

5-6 (4.9-6.0)

Grey-yellow, fluid, frothy

Grade II or grade III
flora (pus-cells, trich-
omonas and mixed bar-
terial flora)

Profuse, mixed

It should, of course, be stated that, while for the purpose

of our investigation, we confined ourselves to virginal cases,
vaginal discharge of non-infective origin may occur in women
not virginal. In fact several patients who were suffering from
leucorrhoea which was not infective, were omitted from this series

because they were not virgins.
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JOURNAL OF OBSTETRICS AND GYNAECOLOGY

The Treatment of Virginal Leucorrhoea. Treatment must
depend on a careful examination of the discharge and, on this, a
determination of the causative process must be made. The method
of investigation employed and recommended is that a spoonful of
the discharge be removed and fresh-drop examination in saline,
smears and cultures and pH estimations made. In the infective
cases, treatment consists in the local application of antiseptics to
the vaginal wall, generally in the form of douches or instillations.
In the case of erosion, infective or simply oversecreting, treat-
ment is directed to its removal or destruction, e.g. by means of
excision or cauterization. With regard to the non-infective cate-
gory, local treatment is not likely to influence the condition.
Theoretically hormonal therapy might prove of value, but we
have tried many preparations and are not satisfied with their
efficacy in this direction. The use of antuitrin S might be sug-
gested as a line of treatment. Numerous varieties of tonics and
vitamin preparations have been given, but the results have been
inconstant and, on the whole, unsatisfactory. The question of the
value of irradiation of the ovaries as a therapeutic measure in
these cases must at present remain unanswered. General medical
treatment may be employed and the nature of the condition may,
with advantage. be explained to the patient. The tendency in
non-infective cases to spontaneous remission and cure (the latter
occurring frequently after marriage) must be taken into account
in assessing the value of any treatment. The important point is
that treatment should not follow along the therapeutic lines
necessary in cases of the infective category. Dilatation and curet-
tage are worse than useless, for, in addition to their being based on
an erroneous conception and not being of any value and hence un-
necessary, they are occasionally followed by infection. It must be
emphasized, therefore, that in deciding the method of treatment,
while a careful clinical history and examination is of value, a full
and careful laboratory examination of the discharge is essential.

4. NoN-INFECTIVE LEUCORRHOEA IN PREGNANCY.

We are here concerned only with vaginal discharge of non-
infective origin occurring in pregnancy. Mention was made in
Part 11 of the tendency to vaginal discharge in pregnant women,
and it was shown that in many cases it consisted of an excess of
the normal vaginal secretion. A series of 280 pregnant women
with vaginal discharge was examined at the antenatal dispensary
of the Royal Maternity Hospital by Dr. Dugald Baird and one of
us (R.C.). Our primary object was to find the incidence of tricho-

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}

BIOLOGY OF THE VAGINA

monas vaginalis associated with vaginitis. The patients chosen
were women who were complaining of discharge or who showed
evidence of vulval irritation, or in whom vaginal examination
showed an excessive amount of secretion although there was
not any complaint of such. Of the total cases, 39 per cent had a
grade I flora, a highly-acid secretion (pH 4.2-4.6) and abundant
epithelial cells without pus cells or trichomonas vaginalis, that is,
the discharge was due entirely to an increased amount of the
physiological vaginal secretion. In 8 per cent a similar secretion
was accompanied by a varying number of polymorpho-nuclear
leucocytes. Although in this series an attempt was not made at
a regular follow-up of the cases, repeated examinations were car-
ried out on a number of women at a later stage of pregnancy, and
confirmation of our earlier findings regarding the change in the
bacterial flora and increased acidity of the secretion was obtained.

The increase in the vaginal secretion in pregnancy probably
has its counterpart in a minor way in the tendency to slight
degrees of vaginal discharge premenstrually. At these periods
the oestrogenic hormone is present in increased amount in the
circulation. In pregnancy the amount of oestrin elaborated in-
creases progressively towards term, whereas the anterior pitui-
tary or similar hormone tends to decrease in amount. Probably
the amount of vaginal secretion also increases as pregnancy
advances, e.g. Miura” estimated that the amount of titratable
lactic acid increased from 0.4 per cent at the beginning to 0.9
per cent at the end of pregnancy. The similarity between the
occurrence of non-infective vaginal discharge in pregnancy nor-
mally and in the non-pregnant woman pathologically is quite
striking, and the causative factor in both states is probably the
same.

5. DISCUSSION.

The question now arises—What is the origin and mechanism of
production of leucorrhoea of non-infective origin? In a previous
section of this work we suggested that the correspondence be-
tween the presence of glycogen in the vagina and the reproductive
period in the human female was evidence that the deposition of
glycogen in the vaginal epithelium was dependent on ovarian
activity. Again, we explained the apparently anomalous
finding of glycogen in the vagina of the foetfis and new-
born child by the presence of oestrin which we demonstrated
in the urine of infants during the first three to four days of life
and which seemed to be derived from the maternal circulation

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JOURNAL OF OBSTETRICS AND GYNAECOLOGY

via the placenta. The results of our investigations, therefore, were
compatible with the view that the presence of glycogen in the
vagina was dependent on a supply of oestrin in the circulation.

The intimate relation between glycogen in the vaginal epi-
thelium and the normal discharge of the vagina suggests that
there may be a similar close relation between abnormal or exces-
sive discharge and an excess of the glycogen in the epithelial cells.
The laboratory findings, bacteriological and chemical, support
the conception that leucorrhoea in the non-infective group is due
to an excessive production of the normal discharge of the vaginal
epithelium. But there is additional evidence in the results of our
investigations in the infant, in the girl at puberty, and in women
during pregnancy. In the new-born infant and for three to four
days after birth, discharge is plentiful but considerably diminishes
and tends to disappear at the same time as oestrin disappears from
the infant’s urine. Scantiness or complete absence of discharge ‘s
constant during childhood until the girl reaches puberty. Then
the normal small amount of the adult virgin appears. Occasion-
ally excessive vaginal discharge may manifest itself as a disturb-
ance of puberty, even prior to menstruation. In pregnant women,
as pregnancy advances, the vaginal flora tends to improve from
a Grade III to a Grade I and simultaneously the amount of
vaginal secretion increases. The relation of oestrin to these various
changes and the demonstration of excess of oestrin in the new-born
infant, in the later stages of pregnancy and in cases of virginal
leucorrhoea, suggest that over-preduction of oestrin is responsible
for excessive deposition of glycogen in the vaginal epithelium and
hence the excessive discharge. It is of interest to note that Raab”™
showed that the liver of animals which had been injected with
oestrin contained two and three times larger amounts of glycogen
than the liver of animals which had not been injected. He con-
cluded that oestrin effected a very considerable formation and
fixation of glycogen.

Our evidence is largely circumstantial and we have not
brought forward direct proof that oestrin, or an oestrogenic hor-
mone, is responsible for the deposition of glycogen in the vaginal
epithelium. Such proof would be afforded by experiments similar
to those carried out on the monkey by Allen™, who after oophorec-
tomy injected active follicular extracts and showed that the
vaginal mucosa of the monkey from being thin and atrophic
resumed much of its normal appearance and thickness. Unfor-
tunately he did not examine the epithelium for glycogen. We
hope to complete our eee by such an experiment.

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BIOLOGY OF THE VAGINA

It need hardly be said that if excess of oestrin produces in-
creased glycogen-deposition, lack or diminution of it may result
in the absence or scantiness of glycogen in the vagina. The de-
fensive mechanism is thus enfeebled and infective vaginitis, e.g.
trichomonas vaginalis vaginitis which is probably endogenous,
that may ensue.

6. SUMMARY.

A combined clinical and laboratory examination of leucorr-
hoea in the virgin was undertaken as a result of which the con-
dition was divided into two categories (1) vaginal discharge of
non-infective origin and (2) vaginal discharge of infective origin.
It is with the former that the present study is mainly concerned
as it is intimately related to our previously reported investigations
on the biology of the vagina.

Vaginal discharge of non-infective origin occurs as a patho-
logical condition in virgins and normally in pregnant women and
is due to an excess of the normal vaginal secretion. The discharge
itself is white, caseous in consistence, highly acid in reaction and
consists of desquamated vaginal epithelium, lymph and Déder-
lein’s vaginal bacilli. It is thus similar in character to the vaginal
secretion of new-born infants and healthy women of the reproduc-
tive period. We have already demonstrated the correlation of
this type of secretion with the presence of glycogen in the vaginal
epithelium, which in turn is dependent upon a supply of the oes-
trogenic hormone. It is suggested that an excess of the oestrogenic
hormone, by causing increased deposition of glycogen in the
vagina, produces the vaginal discharge of non-infective origin
described and discussed in the present paper. Excess of oestrin
occurs normally in pregnancy, particularly in the later stages. In
virginal leucorrhoea, which is not infective, our data suggest that
an excess of oestrin may in certain cases result from a disturbance
of the normal balance between the anterior pituitary and ovarian
hormones.

We are indebted to the Visiting Surgeons of the Royal Samari-
tan Hospital for Women, Glasgow, for access to clinical material;
to Drs. D. Baird, D. P. Cuthbertson, T. K. Maclachlan, and
Bruce MacLean for assistance in certain parts of the investigation;
to Dr. Amy Fleming for laboratory facilities at the Samaritan
Hospital, and to Nurses McPhail and Stewart for their assistance
at the Glasgow Maternity Hospital.

383

NOUPWH

. Allen, E. Contribution to Embryol., Carneg. Inst., 1927, xix, 1.

JOURNAL OF OBSTETRICS AND GYNAECOLOGY

REFERENCES.

. Fischel, W. Arch. f. Gynikol., 1897, xv, 76.
. Fritsch, H. Handbuch der Fravenkrankheiten, Brnschwg, 1885.

Whitehouse, B. Brit. Med. Journ., 1928, i, 651.
Davis, C. H. Amer, Journ Obstet. and Gynecol., 1929, xviii, 1y6.

. Payne, F. L. Amer. Journ. Obstet. and Gynecol., 1929, xvii, 841.
. Burns, J. W. Journ, Obstet. and Gynaecol. Brit. Emp., 1922, xxix, 619
. Kidd, F., and A. M. Simpson. ‘‘Common Infections of the Female

Urethra and Cervix,’’ London, 1929.

. Douglass, M., and M. Ridlon. Surg. Gynecol. and Obstet., 1929, xIviii

408.

. Kinoshita, T. Med. Ges. Tokio, 1907 (quoted from Frank).

. Frankl, O. Liepmann’s Handbuch der Frauenheilkunde, 1914, Leipzig

. Plaut, A. Report on Women’s Hospital, New York, 1925-1928, 293.

. Bonney, V., and B. Glendinning. Proc. Roy. Soc. Med., Lond., 1910, iv,

Part II, Obstet. and Gynaecol., 18.

. Chandler, A. S. Animal Parasites and Human Disease, 1918, New York.
. Gellhorn, G. Amer. Journ. Obstet. and Gynecol., 1901, xliv, 3.

. Kerwin, W. Surg. Gynecol. and Obstet., 1918, xxvii, 151.

. Eichhorst, H. Med. Klin., Berlin, 1912, viii, 1,536.

. Frank, R. T. ‘‘Gynecological and Obstetrical Pathology,’

1931, New
York.

. Fluhmann, C. F. Amer. Journ. Obstet. and Gynecol., 1929, xviii, 832.
. Smith, R. R. Amer. Gynecol., Balt., 1903, iii, 515.
. Meaker, S. R., and W. Glaser. Surg. Gynecol. and Obstet., 1929, xlviii,

73-

. Curtis, A. H. Surg. Gynecol. and Obstet., 1918, xxvi, 178.
. Miura, H. Kyoto-Idakaigaka Zasshi (Mitte. Med. Akad Kioto), 1928,

II, Heft 1.
Raab, E. Arch. f. Gynikol., 1931, cxliv, 284.

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384

The Origin of Columnar Epithelium in the Graafian Follicle
and its relation to the Histogenesis of Ovarian Cysts.
BY

Douctas H. MacLeop, M.S. (Lond.), M.R.C.P. (Lond.),
F.R.C.S. (Eng.), M.C.O.G.

Surgeon to Outpatients, Hospital for Women, Soho Square;
Honorary Gynaecological Surgeon to The Cancer Hospital.

[From the Bland-Sutton Institute of Pathology, Middlesex Hospital. ]

THE nature of cysts of the ovary, other than the simple retention
cysts, has been a much discussed subject and many theories as
to their origin have been propounded, but it cannot be said as
yet that one has been found that is satisfactory. Cysts of the
ovary may take the most bizarre forms, and difficulties arise in
explaining the origin of intermediate types.

The high columnar epithelium seen in the cystadenomata,
whether mucous or serous, is characteristic. It has been sug-
gested that it may arise from the germinal epithelium, the
Graafian follicle, Wolffian relics, teratomata or even from
implantations. The Graafian follicle has for a long time received
attention, but the theory has lacked definite proof (Ewing’). If
it could be shown beyond doubt that the follicular epithelium
(i.e. granulosa cells) is capable of forming a columnar epithelium,
then it is conceivable and highly probable that such an
epithelium may eventually form the epithelial lining of compli-
cated cystadenomata. Kauffman’ states that the transition of
follicular cells into a columnar epithelium has never been seen,
and Goodall’ goes so far as to assert that this is an impossibility.
W. S. Gardiner* in 1932 published a paper on this subject, in
which he showed the presence of columnar epithelium in a
Graafian follicle.

The origin of the simple retention cysts (follicular cysts) is
never disputed. These cysts are often lined by a flattened
epithelium. Wilfred Shaw’ believes that this is developed from
the endothelium of the blood-vessels in the wall. King,° in a
recent paper on epithelium-lined cysts of the ovary, believes that
it arises as a physiological reaction on the part of the tissues in
the wall to the presence of blood in the follicle. If the Graafian-

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follicle theory is true, there must be a very close relation between
the simple retention cysts and the cystadenomata which may be
looked on as proliferative or active forms. It is more likely that
the flattened epithelium in the follicular cysts is developed from
the granulosa cells rather than as Shaw and King suggest.
Further, it is characteristic of all structures developed from the
follicle that they can be readily enucleated from the stroma of
the ovary; the plane of cleavage passes through the loose
vascular lamina outside the theca interna. Small cystadenomata
and chocolate-cysts may similarly be enucleated, and in cases
of involvement of both ovaries in young women, an ovary may
accordingly be conserved. It is noteworthy that small pseudo-
mucinous cysts are rarely seen; possibly they are mistaken in
their early form for multiple follicular cysts.

Virchow*® and the older pathologists held that the Graafian
follicle was responsible only for the simple cysts and that some
other source must be looked for in the case of the more
complicated cysts. Briefly, it would appear that the cystadeno-
mata may develop from the intrinsic or extrinsic sources of
epithelium in the ovary.

(A) Intrinsic sources: Epithelial structures in the ovary itself.

1. The germinal epithelium.

2. The epithelial cells of the follicle.
3. Teratomata.

4. Wolffian remnants in the hilum.

1. The germinal epithelium.

Goodall,* Hofstatter,? McCarty’® "' and others believe that the
germinal epithelium is the starting point of all cystadenomata, and
Nagel’? showed that the inclusion of surface epithelium to form
small cysts often occurs in inflammatory conditions. Flaischlen’’
showed that the germinal epithelium may become ciliated and
Pfannenstiel’* traced a connexion between ciliated germinal
epithelium and small cortical cysts.

2. The epithelial cells of the follicle.

Marchand" and von Velits'® both believe that the Graafian
follicle may be the origin of papilliferous cysts. von Velits has
shown that granulosa cells may become ciliated in certain
animals and Whitridge Williams’? demonstrated the presence of
papillary projections in a follicle. |Pfannenstiel’* believes that
the follicle may also give rise to pseudo-mucinous cysts and

386

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HISTOGENESIS OF OVARIAN CYSTS

argues that the frequent association of pseudo-mucinous cysts
with dermoids is in favour of their follicular origin. Ewing’
states that there is hyperplasia in the remaining follicles in
many cases of cystadenomata.

3. Teratomata.

The frequent association of pseudo-mucinous cysts with
dermoids, the occasional presence of plain muscle in the walls
and the resemblance of the lining to intestinal mucosa led
Wilfred Shaw,'* Ribbert*’ and others to believe that the pseudo-
mucinous cyst is teratomatous in origin.

4. Wolffian relics.

This theory has received support from Clark,” Nagel* and
others, but Goodall® has proved definitely that these tubules never
enter the cortex and can be responsible only for small insignificant
cysts.

(B) Extrinsic sources of epithelium.

1. Tubal inclusions.
2. Endometrial implants.

1. Tubal inclusions.

Marchand" and Whitridge Williams" believed that inclusions
of the mucosa of the Fallopian tube may account for the presence
of certain ciliated cysts.

2. Endometrial implants.

This phenomenon is illustrated by Sampson’s** spill theory to
account for blood-cysts lined by tissue resembling normal endo-
metrium.

Histological evidence and discussion.

The object of this paper is to attempt to bring further
histological evidence in support of the follicular theory. It will
be shown that there is a tendency on the part of the deeper layer
of the granulosa cells to take on an orderly arrangement in the
later stages of development of the follicle (Fig. 1).

Several follicles reach maturity during each menstrual cycle,
but usually only one ruptures, the remaining unwanted follicles
undergo retrogressive changes or may form follicular cysts, the
lining of which varies according to the stage of development of
particular follicle.

These follicles, also, may under certain conditions develop a
columnar epithelium, which may eventually form epithelium-

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lined cysts. These changes are shown in.a series of sections
(Figs. 3, 4, and 5) taken from different portions of the wall of
a Graafian follicle (Fig. 2) which was found in an ovary removed
at operation for multiple chocolate-cysts. The columnar epithe-
lium appears to develop from the deepest layer of the
granulosa cells. These cells, as mentioned, tend to form
an orderly arrangement in the later stage of development of the
normal follicle after the theca interna has appeared (Fig. 1).
This tendency now becomes more marked (Fig. 2), the cells are
taller and their nuclei are seen to lie near the base of the cells.
The more superficial cells gradually approach the cavity of the
follicle, so that a broad clear band is now seen between their
nuclei and those of the basement cells (Fig. 3). The final stage
is the extrusion of these superficial cells and the formation of a
well-marked columnar epithelium (Fig. 4). It is possible that the
epithelium-lined chocolate-cysts in this ovary were formed in this
way. Endocrine disturbances and changes in the normal
structure of the surrounding stroma may be responsible for this
change. The primordial follicles normally lie in a wavy, richly
cellular lamina sharply marked off from the rest of the cortex.
Further, this lamina is often absent or markedly changed in
grossly abnormal ovaries. It is reasonable to expect that for the
healthy development of a primordial follicle, the medium in
which it lies should be suitable for its growth. Alterations in the
structure of such a medium may lead to development along
abnormal lines.

If it is accepted that follicular epithelium is capable of
developing into a columnar epithelium, the possibility that the
follicle may be the origin of cystadenomata and other ovarian
epithelial tumours cannot be ignored. There is a close relation
between the granulosa cells of the follicle and the lining cells of
the Miillerian cord. Both arise from invaginations by the meso-
thelial cells of the splanchnopleure (modified in the case of the
ovary into germinal epithelium) and are of a common origin.
The cells burrowing into the Miilerian cord eventually
canalize and form the epithelium peculiar to the different
portions of the female genital tract. It is not unreasonable to
expect, if the granulosa cells are capable of forming an
epithelium, that epithelium may, in a like manner, vary con-
siderably in type, and the occurrence of cysts differing widely
from one another might be explained on this basis and render
unnecessary all the several theories claborated to avoid this
obstacle.

388

ek
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Fic. 2.
SE
5
oF

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=
Fic. 3.
Fic. 4.
oF
\

HISTOGENESIS OF OVARIAN CYSTS

I am indebted to the members of the staff of the Middlesex

Hospital for their kind permission to make use of the cases under
their care.

REFERENCES.

1. Ewing. ‘‘Neoplastic Diseases,’’ 1928, W. B. Saunders & Co., 624.

II.

12.

. Kauffman, Edward. ‘‘Pathology,’’ 1929, ii, 1552.
. Goodall, J. R. ‘‘Origin of tumours of the ovary.’’ Surg. Gynecol. and

Obstet., 1920, ii, 249.

. Gardner, W. S. ‘‘On the origin of ovarian epithelium.’’ Amer. Journ.

Obstet. and Gynecol., 1932, xxiii, 54.

. Shaw, Wilfrid. ‘‘Some pathological forms of corpus luteum.’’ Journ.

Obstet. and Gynaecol. Brit. Emp., 1927, xxxiv, 316.

. King, E. S. J. ‘‘Epithelium-lined blood-cysts of the ovary.’’ Australian

and New Zealand Journ. Surg., 1932, ii, 347.

. MacLeod, D. H. ‘“‘Struma ovarii (thyrodermoid). A note on the

teratomatous origin.’’ Proc. Roy. Soc. Med., 1932, xxv, 64.

. Virchow. Ewing’s ‘‘ Neoplastic Disease,’’ 1928.
. Hofstatter. ‘‘Vorkommen des primaren Oberflachenpapilloms.’’ Arch.

f. Gyndkol., 1919, 110, I.

. McCarty, R. B. ‘‘Histogenesis and tendency to bilaterality of papillary

”

cysts of the ovary.’”’ Surg. Gynecol. and Obstet., 1932, liv, 188.
McCarty, R. B. ‘‘Contribution to histogenesis of papillary ovarian
cysts.’’ Proc. Staff. Meet. Mayo Clinic., 1930, v, 132.

Nagel, W. ‘‘Beitrag zur Genese der epithelialen Eirstocksgeschwiilste.’’
Arch. f. Gyndkol., 1888, 33, I.

. Flaischlen, N. ‘‘Zur lehre von der Entwickelung der papillaren Kystome

oder multilocularén Flimmerepithelkystome des Ovarium.’’ Zeitschr.
f. Geburtsh. u. Gynikol., 1881-1882, 6-7, 231.

. Pfannenstiel, J. ‘‘Die Genese der Flimmerepithel. Geschwiilste des

Eierstockes.’’ Arch. f. Gynikol., 1891, 40, 363.

. Marchand, F. ‘‘Beitrage zur Kenntniss der Ovarien-tumoren.’’ Halle,

1879, Quarto tracts, 43.

. von Velits. ‘‘Beitrage zur Histologie und Genese der Flimmerpapillar

Kystomen des Eierstocks.’”’ Zeitschr. f. Geburtsh. u. Gyniikol., xvii,
232.

. Williams, J. Whitridge. ‘‘Contributions to the histogenesis of the

papillary cystomata of the ovary.’’ Bull. Johns Hopkins Hosp., 1891,
ii, 149.

. Pfannenstiel, J. Kauffman’s ‘‘Pathology,’’ t929, ii, 1567.
19.

Shaw, Wilfred. ‘‘The pathology of ovarian tumours.’’ Journ. Obstet.
and Gynaecol. Brit. Emp., 1932, XXxix, 234.

. Ribbert. Ewing’s ‘“‘Neoplastic Disease,’’ 1928, 650.
. Clark, J. G. ‘‘Histogenesis of glandular cysts of the ovary.’’ Trans.

Amer. Gynecol. Soc., 1903, 28, 312.

. Nagel, W. ‘Entwickelung und Entwickelungsfehler der weiblichen

Genitalien.’’ J. Veit. Handbuch der Gynikol., 1897, 1; 519.

. Sampson, John H. ‘Benign and malignant endometrial implants in the

”

peritoneal cavity and their relation to certain ovarian tumours.
Gynecol. and Obstet., 1924, xxxviii, 287.

389

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Some Aspects of the Chemistry of Haematocolpos Fluid

By JosEPH S. MITCHELL, B.A., B.Ch. (Cantab.).

(From the Department of Gynaecology and Obstetrics,
University of Birmingham and the General Hospital,
Birmingham).

THE clinical features of two cases of haematocolpos are
summarized and chemical analyses of the fluid removed are
given. The results are discussed chiefly from the points of view
of the secretion of calcium and iodine into the uterine cavity;
the inadequacies of the present chemical data are pointed out,
and a possible physico-chemical explanation of the high con-
centration of calcium in haematocolpos fluid is suggested.

CLINICAL HIsTORY.

Case 1. L. H., age 153 years, was admitted to the General
Hospital, Birmingham, complaining of pain and swelling of four
months’ duration in the lower abdomen. There had never
been any vaginal loss, but the pain occurred at, approximately,
monthly intervals, and when the pain was at its height she
noticed that the ‘abdominal swelling increased in size. There
were no urinary symptoms. The uterus, resting above the
haematocolpos, was palpable as a rounded swelling rising out
of the pelvis. in the middle line and extending to about two inches
above the symphysis pubis. A thin bulging membrane somewhat
blue in colour occupied the vaginal orifice and the hymen did not
appear to be separate.

The hymen was excised and 12 fluid ounces of viscous
chocolate-coloured fluid drained away.

Case 2. L.R., age 16 years, complained that for about six
months she had suffered from periodical pain in the lower
abdomen, occurring every four to five weeks and lasting about
six to seven days on each occasion; there had never been any
vaginal loss but there had recently been some difficulty in mictu-
rition. She was admitted to the General Hospital, Birmingham,
and on examination a small, tender, rounded swelling was found,
rising out of the pelvis in the middle line and extending to about
two inches above the symphysis pubis. The vaginal orifice was
occupied by a thin, bulging membrane and there was not any

390

CHEMISTRY OF HAEMATOCOLPOS FLUID

evidence of a separate hymen. She was transferred to Tamworth
Hospital where the hymen was excised, and 10 fluid ounces of
viscous chocolate-coloured fluid were evacuated.

CHEMICAL ANALYSIS.

The fluid from Case 1 was analysed by Mr. Garfield Thomas
at the Department of Biochemistry, and that from Case 2 by Dr.
D. L. Woodhouse at the Cancer Research Laboratory, of the
General Hospital, Birmingham.

Case I.
Glucose: 29 mg. of glucose per r00 c.c. of fluid.
The glucose was estimated about four hours after removal
of the fluid.
Sodium chloride : 445 mg. sodium chloride per 100 c.c. of fluid.
Cholesterol: 132 mg. of cholesterol per roo c.c. of fluid.
Calcium: 9.7 mg. of calcium per 100 grm. of fluid.
The calcium was estimated by the method of Alport’.
Iodine: go iodine per 100 grm. fluid.
The iodine was estimated by Lunde’s modification of v.
Fellenberg’s method."*
Manganese: 8 per 100 grm. fluid.
The manganese was estimated by a slight modification of
Richard’s"’ method.
An attempt was made to separate the cells by centrifuging,
but only a very small amount of serum was obtained. It is
interesting to note that the fluid did not clot.

Case 2.
Calcium: 9.7 mg. of calcium per 100 grm. of fluid.
The calcium was estimated by a slight modification of the
method of Kramer and Tisdall’.

Iodine: 98 per 100 grm, fluid.

The method of iodine estimation used may be briefly summarized.
Twenty grammes of fluid were heated cautiously in a nickel crucible with
10 c.c. of 20 per cent KOH until all organic matter was destroyed and a clear
melt obtained. The residue was extracted with warm water and neutralized
with slight excess H,SO,. Excess AgNO, (+HNO,) was added and the
solution allowed to stand 24 hours. The precipitated chloride and iodide
were boiled with chlorine water to oxidize iodide to iodic acid. The excess
chlorine was then expelled, the solution filtered and the filtrate treated with
10 per cent Kl. The precipitated iodine was extracted with CCl, and
estimated by matching the colour of the solution with a standard iodine
solution.

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JOURNAL OF OBSTETRICS AND GYNAECOLOGY

Oestrin: Tests with immature mice yielded negative results.

DISCUSSION OF THE ANALYSIS.
Calcium.

The great variations found among the older estimates of the
amount of calcium in normal serum, corpuscles and the whole
blood, appear to be due largely to the untrustworthiness of the
methods of estimation but, as is well known, the advent of micro-
methods of analysis introduced a new phase of blood chemistry.

Lyman" stated that the calcium content of whole human
blood showed a definite sex variation, being 6.1 mg. per
100 c.c. in the male and 7.1 mg. per 100 c.c. in the female,
and Blair Bell’ observed a pre-menstrual rise of serum-calcium,
the onset of the menstrual period being followed by a marked
fall. These findings, however, appear not to have been entirely
confirmed.**

Kramer and Tisdall’ estimate the calcium in whole blood as
5.3 to 6.8 mg. per 100 c.c. and Alport’ gives the value as 5.8 mg.
per I00 c.c¢.

The generally accepted figure for the calcium content of
normal human whole blood is 5.6 to 6.3 mg. of calcium per
100 c.c. of blood, while normal serum contains 9.6 to 10.6 mg. per
100 c.c., and in connexion with the present investigation, any
possible difference between the calcium content of serum and
plasma must be considered. Mazzocco,'* and Halverson,
Mohler and Bergeim’ stated that the calcium content of serum
and plasma were practically identical, but Stewart and Percival’®
found that in true plasma obtained by rapidly cooling and
centrifuging blood drawn under liquid paraffin, the calcium
content is Io to 15 per cent higher than that of the serum.

From the analysis given, it is quite certain that the calcium
content of haematocolpos fluid is much higher than that of
normal blood, especially in view of the greater proportion of
corpuscles present, for it is quite well accepted that the calcium
content of red blood-corpuscles alone is very small, in fact
Leiboff'" has recently shown that calcium is entirely absent from
the human red blood-corpuscie. Thus the data submitted con-
firm those of Blair Bell* given in his well known paper of I91T,
and it must also be pointed out that the clinical histories of his
cases were almost certainly of longer duration than those of the
cases presented here, thus perhaps accounting for his rather
higher estimate of the calcium content of haematocolpos fluid at
12.6 mg. Ca per cent. In passing, it is interesting to note here

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CHEMISTRY OF HAEMATOCOLPOS FLUID

that the calcium content of amniotic fluid*’ is almost constant at
approximately 11 mg. per 100 c.c. But what is most
important is the consideration of the correctness of Blair Bell’s
assumption that the increased calcium in haematocolpos fluid is
due to active secretion. That the present analyses by themselves
are inadequate to prove or disprove this will be shown below, but
the possibility of explaining the high calcium content on the basis
of Donnan’s principle of membrane equilibrium, without invok-
ing any mechanism of secretion by living cell membranes,
demands full investigation.

The structure of the cells between the haematocolpos fluid and
the blood is immaterial in the present considerations, and the
separating membranes can be satisfactorily represented by a
membrane freely permeable to inorganic ions and water and
impermeable to protein ions and molecules. On both sides of
the membrane is a suspension of red blood-corpuscles in a
plasma-like fluid. The corpuscles are impermeable to K, Ca,
phosphate, sulphate and, of course, protein ions, but permeable
to Na, NH, and chloride ions and to water.** Numerous observa-
tions*’ have shown that about 40 per cent of the serum calcium
is indiffusible although precipitated by ammonium oxalate, this
being due almost entirely to the formation of calcium pro-
teinates'' ** at the fH of blood. The conception of supersatura-
tion of the blood with Ca* (PO,),. put forward by Holt* is very
difficult to accept, and the calcium content of the plasma of
the blood and haematocolpos fluid can be regarded as approxi-
mately 60 per cent free Ca** ions and 40 per cent as Ca pro-
teinate, which has a very low degree of dissociation.

The only ions on each side of the membrane between the
blood and the haematocolpos fluid which are induffusible are the
protein anions, so that if the system is in equilibrium, simple
thermo-dynamical considerations show that

[Ca], [Ca].
where the square brackets (as usual) signify ionic concentrations
and the suffixes denote the sides of the membrane.

To test this, the concentrations of calcium and chloride must
be estimated in the piasma of the haematocolpos fluid, and
the value of the corresponding product compared with the known
value for normal plasma; any difference in the two products
outside the range of experimental error seems to require explana-
tion by some other mechanism best described, perhaps, as active
secretion.

So that, though at present the required data are not available,

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it appears entirely unjustifiable to assume that the uterus secretes
calcium, until the simple physico-chemical explanation suggested
can be disproved by experimental measurements.

Todine.

There appears to be general agreement’ that the average value
for the total iodine in normal blood is 8 to 13y per 100 c.c. and the
limits of normal variation 5 to 207 per 100 c.c. It has been shown
that about 34 per cent of the total iodine is inorganic and the
remaining 66 per cent organic'’. The total iodine is apparently
slightly less in the winter than in the summer, and the inorganic
fraction is the more variable.

From the analysis given, and despite the considerable difficul-
ties of exact determination, it appears certain that the iodine
content of haematocolpos fluid is much higher than that of normal
blood. The form in which the iodine is present was not studied,
and at present there does not appear to be any direct evidence
whether thyroxin or di-iodotyrosine (or both) are present in
normal blood. It is impossible to consider any explanation like
that given for calcium in this case.

The high iodine content of haematocolpos fluid is of especial
interest in view of the recent work‘ showing the effect of thyroxin
(but not desiodothyroxin) in prolonging the active life of
spermatozoa.

Chloride.

It is generally accepted that the chloride content of human
whole blood is equivalent to 470 to 520 mg. of NaCl per 100 c.c.,
and of plasma, 570-620 mg. NaCl per 100 c.c., so that in view
of the large amount of red corpuscles in haematocolpos fluid there
is no gross departure from the value to be expected. As pointed
out above, the investigation of the mode of transfer of calcium
into the uterine cavity requires an accurate estimation of the
chloride content of the serum of haematocolpos fluid.

Cholesterol.
The cholesterol content of the fluid from Case 1 is within the
limits of normality for normal blood.

Manganese.

The estimation of manganese is rather difficult and the value
for normal blood appears to be about 5y per Too c.c., so that the
value quoted in the analysis cannot be said to indicate the concen-
tration of manganese in the uterus.

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Lactic Acid.

In view of the glycolysis occurring in normal blood on stand-
ing, before any definite light on the importance of Déderlein’s
bacillus in the production of lactic acid* can be shed by analysis of
haematocolpos fluid, the lactic acid must be estimated as soon as
possible after removal of the fluid and the time of examination in
relation to the last menstrual period noted; also it is possible that
the lactic acid content varies considerably in different parts of the
collection of fluid.

It appears quite possible that the ordinary glycolysis will
adequately explain the lactic acid present, without any need for
invoking the action of Déderlein’s bacillus or the breakdown of
mucin by enzymes."

Finally, I have to thank Professor Beckwith Whitehouse for
his kindness in suggesting the present investigation, and Mr.
Garfield Thomas and Dr. D. L. Woodhouse for kindly supplying
the details of the analyses.

REFERENCES.
. Alport, A. C. Biochem. Journ., 1924, xviii, 455.
2. Blair-Bell, W. Proc. Roy. Soc. Med., 1908, i, 291.
. Blair-Bell, W. Lancet, 1911, i, 1269.
. Carter, G. S. Journ. Exper. Biol., 1932, ix, 378.
. Dodds, E. C., W. Lawson and J. D. Robertson, Lancet, 1932, ii, 608.
. Déderlein, E. ‘‘Das Scheidensekret.’’ Leipzig: 1892.
. Halverson, J. O., H. K. Mohler and O. Bergeim. Journ. Amer.. Med.
Assoc., 1917, xviii, 1307.
. Holt, L. E. Jr., V. K. La Mer, and H. B. Chown. Journ. Biol. Chem.,
1925, Ixiv, 509, 567, 579.
. Kramer, B. and F. F. Tisdall. Journ. Biol. Chem., 1932, xlvii, 479:
1921, xlviii, 223.
. Leiboff, S. L. Journ. Biol. Chem., 1930, 1xxxv, 759.
. Loeb, R. F. Journ. Gen. Physiol., 1926, viii, 451.
. Lunde, G., K. Closs and O. C. Pedersen. Biochem. Zeitschr., 1929,
ccevi, 261.
. Lyman, H. Journ. Biol. Chem., 1917, xxx, I.
. Mazzocco, P. Journ. Chem. Soc., 1922, Ai, 789.
‘5. Nitzescu, I., and E. Binder, C.R. Soc. Biol., Paris, 1931, cviii, 279.
. Northrop, J. H., and M. Kunitz. Journ. Gen. Physiol., 1924, vii, 25.
. Richards, M. Analyst, 1930, iv, 554- ;
. Sherman, H. C., L. H. Gillett and H. M. Pope. Journ. Biol. Chem..
1918, xxxiv, 373.
. Stewart, C. P. and G. H. Percival. Physiol. Reviews, 1928, viii, 283.
. Uyeno, D. Journ. Biol. Chem., 1919, xxxvii, 77.
. Weill, J. C.R. Soc. Biol. Paris, 1932, cix, 925.
. Widdows, S. T. Biochem. Journ., 1923, xvii, 34.
. Woodhouse, D. L., and F. A. Pickworth. Biochem. Journ., 1932, xxvi,
309.
395

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2

Ligature of the Open Abdominal End of the Fallopian
Tube in Cases of Incipient Salpingo-Peritonitis.
BY
JAROSLAV E cart, M.D.

THE operative procedure which I recommend in this paper was
performed in the first two cases following a mistaken diagnosis.
In the first case the diagnosis of appendicitis was incorrect; the
second case was one of combined appendicitis and salpingo-
peritonitis. The statement by Sellheim and Sachs that these two
diseases can be differentiated by the symptom of pain on vaginal
pressure of the broad ligament, or by the sign of a swelling in
the broad ligament, is not always correct. The diagnosis is very
difficult when both diseases are present, although the diagnosis
proves more trustworthy when there is a vaginal discharge. A
combination of these two diseases in chronic cases occurs, accord-
ing to Pankow, in 22 per cent, and in my experience in acute
appendicitis nearly 5 per cent. I have now operated upon
more than 3800 cases of appendicitis with a mortality rate of 1.8
per cent. Though the salpingo-peritonitis can usually be treated
in a conservative way, delayed treatment in appendicitis may be
fatal. These considerations have led me to change my method of
treating salpingo-peritonitis combined with appendicitis,and such
treatment has proved successful also in cases in which the diag-
nosis of salpingo-peritonitis is certain.

Ten years ago I formed the opinion that ligature of the open
abdominal end of the Fallopian tube in salpingitis would prevent
the escape of pus into the abdominal cavity. I was only doubtful
whether I should perform this operation in bilateral disease and
further whether the ligature would be sufficient, or whether I
should, in addition, invaginate the end of the ligated tube. T
finally chose simple ligation of the tube without invagination on
the assumption that this would prevent the escape of pus for
several days until sufficient adhesions were formed to localize
the infection of the peritoneum. This conclusion has proved
correct.

I expected further that the continued secretion in the ligated
tube would produce such an internal pressure therein that the
pus would be forced into the cavity of the uterus, so that the

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INCIPIENT SALPINGO-PERITONITIS

possibility of a closed pyosalpinx (sactosalpinx) occurring later
would be lessened since the uterine ostium of the tube would
remain open.

When I reported the first cases at the conference of surgeons
and gynaecologists at Prague in 1922, Rubeska maintained that
salpingo-peritonitis could usually be cured by conservative treat-
ment, and he recommended laparotomy only in cases of general
peritonitis. Tuma emphasized the fact that inflammation extended
by the escape of pus not only through the open abdominal end of
the tube but also through the wall of the tube when its abdominal
end is ligated.

These objections have only a relative value. If operative
treatment is reserved exclusively for diffuse peritonitis and the
expectant treatment for commencing salpingo-peritonitis, the
patient is exposed to grave danger, because in advanced cases
of peritonitis the operation is not always successful. I had such
a case as this: A patient with Graves-Basedow disease was ad-
mitted with diffuse salpingo-peritonitis and a pulse-rate of 180.
The operation could not be postponed until her pulse became
normal. She died the third day after laparotomy.

I have till now but little experience with my method in cases
of puerperal peritonitis, so that my present paper relates only to
non-puerperal salpingo-peritonitis.

I agree with Tuma. With my method inflammation also
spreads through the wall of the tube. The ligature, however, not
only prevents the sudden escape of pus from the Fallopian tube,
but also the slow diffusion of inflammation through the wall of
the tube is desirable since protective adhesions are thus formed.
Diffuse peritonitis did not develop in any patient after the appli-
cation of the ligature.

The criticisms of Tuma are, therefore, only of relative value.
I claim the following advantages for my method:

1. The operation is practically safe, since of the 50 cases of
incipient salpingo-peritonitis I have operated upon not one has
proved fatal.

2. Fever, vomiting and pains disappear, as a rule, on the
second or third day after the operation.

3. In only one case did peritonitis spread into the abdomen,
and that was when I cut the fimbriae too close to the ligature so
that it later became loose.

4. At the operation the doubt as to whether appendicitis or
salpingitis is present, or whether they are combined is settled.

5. The subsequent development of a closed pyosalpinx (sacto-

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salpinx) very rarely follows ligature of the abdominal end of the
tube because the pressure of the pus in the tube keeps patent the
canal leading to the cavity of the uterus. I believe that in this
way the chance of impermeability of the lumen of the tube be-
tween its ligated end and the cavity of the uterus is distinctly
lessened.

6. The ligature of the tube also protects the patient against
subsequent extra-uterine pregnancy.

Only one patient had a sactosalpinx when discharged and that
was small. Another patient complained of pain on vaginal ex-
amination, but infiltration was not present. In the first case the
tube was much thickened at the operation; in the second case de-
formed and perhaps impermeable. In two other cases I explored
the patency of the Fallopian tube by abdominal injection of lipio-
dol during the operation.

I have also had the opportunity of checking the subsequent
effect of the ligature. I had to reopen the abdominal cavity of
one patient because the uterus was fixed in a retroverted position,
and I found the tube which I had previously ligated closed and
empty and its wall a little thickened. The second patient was
operated upon in 1927 for suppurative salpingo-peritonitis com-
bined with acute appendicitis. I removed the appendix and lig-
ated the right Fallopian tube. In 1928 Dr. Mourek removed the
left ovary and tube for a tubo-ovarian abscess at the Bohumin
Hospital, and found that the previously ligated right tube was
only a little thickened at its closed end and covered with very fine
adhesion. In 1933 the same patient was admitted to the Zlin
Hospital and Dr. Albert found a slight thickening in the right
tube and pain on palpation. The patient was treated conserva-
tively for 10 days and then dismissed as satisfactorily improved.

This case is a very convincing proof and justifies my state-
ment that in practically all cases the Fallopian tube remains
patent between its ligated end and the cavity of the uterus.
Neither sactosalpinx nor occlusion of the lumen followed, as was
proved by the subsequent recurring infection. This case provides
still further information. I previously considered the ligature of
both tubes as inadvisable except in the case of prostitutes, so that
I merely disinfected the other tube with iodine. This case, how-
ever, convinced me that a bilateral ligature avoids the develop-
ment of sactosalpinx. Both tubes are in this way converted into
lateral sinuses communicating freely with the cavity of uterus,
so that a sactosalpinx can but seldom follow.

398

INCIPIENT SALPINGO-PERITONITIS

The technique of my method is very simple: If the acute
abdomen is combined with a vaginal discharge I always perform
laparatomy with an 8 to 10 centimetre medial or paramedial inci-
sion in the hypogastrium. After removal of the appendix the
Fallopian tube is gently massaged and if pus is expressed I then
ligate and remove its abdominal end near the fimbriae and disinfect
the remaining part of the tube with iodine. The end of the tube
should be severed about 0.5 centimetre from the ligature to prevent
the latter becoming loose. Ligature of the remaining tube should
be performed only when a discharge of pus is present. In two
patients who had a profuse discharge of pus I also invaginated
the ligated ends of the tubes, but I believe nowadays that this is
unnecessary. The pelvis should be thoroughly cleansed and then
the abdomen closed. Only a thin subcutaneous drainage is
necessary.

My method does not replace the resection of a chronic closed
pyosalpinx (sactosalpinx), and is indicated onlyin a patient whose
tube is for the first time acutely inflamed, and at the beginning
of her illness. Later, if desirable, the ligated and invaginated
abdominal end of the Fallopian tube can be rectified by a salpin-
gostomy.

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CARCINOMA OF THE CERVIX UTERI IN
PREGNANCY AND LABOUR.

I
Werthiem’s Operation at Term, without Caesarean Section.

CARLTON OLDFIELD, M.D. (Lond.), F.R.C.P. (Lond.),
F.R.C.S. (Eng.).

Consulting Gynaecological Surgeon, Leeds General Infirmary
and Hospital for Women at Leeds.

Mrs. H., a widow, aged 31, had had four children, the first still-
born. She attended the antenatal clinic at St. James’ Hospital,
Leeds, and was treated as a case of normal pregnancy. Labour at
term started at 3 a.m. on June 27, 1933. The membranes ruptured
spontaneously at 10 p.m. the same day two hours after admission
to the hospital. The vertex presented and was floating above the
brim. At II p.m. a rectal examination was made and a hard
irregular mass was felt on the left side of the pelvis. This ex-
amination was followed by a vaginal examination, when a hard
warty growth on the posterior part of the cervix was felt. The
growth was not friable. The os was about the side of a florin.
On further inquiry the patient admitted that she had had a slight
discharge of blood during November and December 1932 and in
April 1933. During labour there was not any bleeding either
before or after the vaginal examination. At 4 a.m. on June 28th
the cervix had dilated to the size of a five-shilling piece. Mor-
phine gr. § with hyoscine gr. 1/100 were injected: rest and
some sleep followed. At 4.45 p.m. the patient was having strong
expulsive pains at short intervals. The pulse-rate was 110. The
head was still above the brim and the child was alive. Two small
portions of the growth were removed by punch-forceps and free
haemorrhage followed. The pieces of growth removed were sent
to the pathological department of the General Infirmary for micro-
scopical examination, and two hours later, when the diagnosis
of carcinoma had been confirmed, Wertheim’s hysterectomy was
performed under ether anaesthesia. Caesarean section was not
performed. The left ureter was adherent to the growth. The
vagina was sutured and the abdomen closed by the usual method.
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CARCINOMA OF THE CERVIX UTERI

At the end of the operation the patient’s pulse was rather rapid,
but her general condition was good. She passed a good night,
had a pulse-rate below 80 the next day, and made an uneventful
recovery without pyrexia or raised pulse-rate. On July 14th,
1933, i.e. just over a fortnight after the operation, she was trans-
ferred to the radium department of the Leeds General Infirmary
and a dose of 4500 milligram-hours of radium was given in three
applications, followed by deep X-ray therapy to the pelvic
region.

The patient has remained well since, and when seen on Feb-
ruary 21st, 1934, appeared to be quite well. In the roof of the
vagina was a little thickened tissue, and a narrow tight band
anchored this part to the side of the pelvis. There was not any
ulceration, and bleeding did not occur on digital examination.

Werthiem's Operation at Term, preceded by Lower
Segment Caesarean Section and followed by Radium
Treatment.

BY
ANDREW M. Crave, M.D. (Leeds), F.R.C.S., Eng., F.C.O.G.

Honorary Assistant Surgeon, Hospital for Women at Leeds;
Honorary Obstetric Surgeon, Leeds Maternity Hospital

Mrs. M. M., aged 36, had had seven children, all born normally
at term except one, which was stillborn at 36 weeks. I was
asked to see her at home about 6 a.m. on March Ist, 1932, be-
cause her doctor thought the cervix was abnormal. On vaginal
examination I felt a hard patch in the cervix, which I diagnosed
as carcinoma. A history of abnormal bleeding or discharge could
not be obtained. The patient was removed at once to Leeds
Maternity Hospital and examined under anaesthesia, when the
cervix was seen to be the seat of a dense pale growth. The
growth did not bleed on scraping, and was not friable. The ex-
ternal os was not dilated. There was some involvement of the
left parametrium, without impairment of mobility. A specimen of
the growth was with some difficulty excised for biopsy. A live
female child weighing 9 pounds 10 ounces was delivered by lower
segment Caesarean section. The abdomen was closed with drain-
age. Recovery was normal: the highest temperature recorded
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JOURNAL OF OBSTETRICS AND GYNAECOLOGY

was 9g.2°F., on March 2nd. Dr. Hickman’s report on the his-
tology of the growth was as follows: ‘‘ This shows a peculiar and
very irregular type of carcinoma, probably of cervical origin.’’
Professor Matthew Stewart kindly looked at the slide in March
1934, and agreed with the report. On March t2th, 1932, the
patient was transferred to the Hospital for Women at Leeds, and
on March 13th radium treatment was begun. Cystoscopy did not
reveal any abnormality in the bladder.

Forty milligrams of radium (four to-milligram tubes in a bent
silver container) were inserted into the uterus, and two Heyman’s
boxes, one containing nine 5-milligram tubes and the other
six 5-milligram tubes, making 75 milligrams in all, were placed
against the vaginal aspect of the growth for 20 hours. The screen-
age in each case was equivalent to 3 millimetres of lead. This
dosage of radium was repeated on March 2oth, and again on
April roth. The patient developed a small radium burn at the
upper end of the vagina, which had healed by October 1932: at
this date the portio vaginalis had also disappeared. She has
attended the out-patient department regularly since treatment,
monthly during the first year, and two-monthly during the
second. She was last seen on March 5th, 1934, when she was
free of signs of disease and of any symptoms. She did not
receive any post-operative X-radiation. During the past 15
months all my cases of cervical carcinoma have received a
post-operative course of X-ray treatment from Dr. Cooper at the
Leeds General Infirmary.

III
Wertheim’s Operation at Term, following the Classical
Caesarean Section preceded by Radium Treatment
during Pregnancy.
BY

Comyns BERKELEY, M.D. (Cantab.), M.C., F.R.C.P. (Lond.),
F.R.C.S. (Eng.), F.C.0.G.

Consulting Gynaecological Surgeon to the Middlesex Hospital
and Chelsea Hospital for Women.

On May aist, 1914, Mrs. E. B., aged 34 years, was admitted to

my ward at the Middlesex Hospital, complaining of slight inter-

mittent haemorrhage since February, and since April of a little
402

CARCINOMA OF THE CERVIX UTERI

discharge which was at times offensive. The patient was 26
weeks pregnant. On vaginal examination there was an irregular
indurated ulcer on the posterior lip of the cervix. The rest of
the cervix was soft and on rectal examination there was not any
sign of parametric infiltration.

A piece of the ulcer was excised and the pathological report
stated that the condition was one of squamous-celled carcinoma.

When it was conveyed to the patient that her condition was a
very serious one and demanded an operation which would
sacrifice the child and prevent any further chance of pregnancy,
she flatly refused to undergo it, since she and her husband, who
was a Sailor and away at sea, were most anxious to have a child.

It was at this time that radium was becoming more generally
used in England, and although I had been using it for cancer of
the cervix since 1910, I had had but little success. This want of
success was due to the fact that only advanced cases were being
treated with radium and partly, no doubt, to the fact that the
technique, as we know it to-day, had not been developed.

I informed Mrs. E. B. of the great danger she was running,
since during the next 14 weeks the cancer would grow very
quickly and that although it might be possible to obtain a living
child at term, nevertheless she was running a great risk of
sacrificing her life on the chance that she might have a living
child. As she remained adamant, I suggested to her that I
should treat the growth with radium, since this would destroy it
locally and I did not believe that the child would be harmed.
She agreed to this.

Accordingly on May 23rd and on June 18th, I inserted into
the growth 232 milligrammes of radium in the form of needles
of 0.5mm. of platinum, each time leaving them im situ for eight
hours, after which the patient left the hospital free of haemorrhage
and discharge.

At term, on August 30th, before an audience composed of a
large number of members of the American Gynaecological
Society, who had been travelling in Europe, and whose return
to America was delayed by the War, I delivered a female child
by the classical Caesarean method. Having sewn up the uterine
incision, I then proceeded to perform Wertheim’s radical opera-
tion for carcinoma of the cervix, removing the iliac and
obturator glands on each side. The child had two bald patches
on an otherwise hairy head, these being surely due to the action
of the radium. The patient made a normal recovery.

The patient and her daughter remain quite well to-day, the

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JOURNAL OF OBSTETRICS AND GYNAECOLOGY

latter being 20 years old. When 15 years of age she cleared a
height of five feet two inches in a jump, which, had she entered,
would have made her the woman Olympic champion high jumper.

Normal Delivery at Term, preceded by Radium

Treatment during Pregnancy

By Pror. A. W. W. Van Rooy, M.D., Amsterdam.

Director of the University Obstetrical and Gynaecological
Institute.

LATELY we had in our clinic the opportunity of treating a case of
carcinoma of the cervix which was discovered during pregnancy.
It has been our custom to operate on cases of carcinoma of the
cervix during pregnancy by the method of Wertheim, so long as
the child was not capable of extra-uterine life; if there was a chance
of the child surviving, say, after 28 weeks of intra-uterine life, to
perform Caesarean section and then to remove the uterus by
Wertheim’s method. In the case now reported the woman was
4I years of age, who already had ten children, and was four
months pregnant. The first time she was examined a typical
cauliflower-like tumour at the portio was found. A test-excision
confirmed the diagnosis of epithelioma of the portionis uteri.
There was no infiltration of the walls of the vagina or of the
parametria. The patient emphatically refused to have the preg-
nancy terminated and the uterus removed.

For this reason we decided to treat her with radium, as is
usual in our clinic in cases of carcinoma of the uterus. During
the period of June oth to June 17th 1933, a dose of 4,200
mg. hour RaEl was given. As the result of this treatment the
tumour disappeared quickly, and when the patient was dismissed
on July 27th the portio appeared to be smooth, somewhat rough
and hard in consistence. The patient was kept under observa-
tion and the pregnancy developed normally.

The portio did not alter, and on December 20th, 1933, the
patient was admitted to our obstetrical department for her con-
finement which was expected about the middle of January 1934.
As we anticipated serious difficulty in the dilatation of the os
due to the rigidity of the portio after the radium treatment, we

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CARCINOMA OF THE CERVIX UTERI

decided to await the commencement of labour and then, if
necessary, to perform a Caesarean section.

On January roth the pains began and the cervix dilated
quickly, so that in a period of about eight hours a child weighing
8 pounds I0 ounces was born spontaneously. The delivery of
the placenta did not cause any difficulty. During the puer-
perium not a single complication took place. The highest
temperature was 99 F. The child was quite normal. An X-ray
chotograph of the skull was taken and showed that the skeleton
was without any abnormality.

On January 26th the mother was dismissed, with her child in
good condition. After that we gave, from February gth till
February 15th, the portio a second radium treatment, till a total
dose of 7,200 mg. hour RaEl was reached. The patient has
since then remained under continual observation. The child
remains also under observation, grows quite normally, and gives
the impression of perfect health. The future will show if, later on,
one can observe any abnormalities in the cerebral functions of the
child.

Such abnormality is not at all to be expected for certain, as
proved, among others, by the observations of Jeitz, who in 1928
treated an exactly similar case in the same way. Of this case it
is known that the child.until now has developed quite normally.’

This case has taught us two things: (z) That by means of
radium the rapid disappearance of a growth projecting into the
vagina can be obtained during pregnancy. (2) That during
labour dilatation of the cervix progresses normally. What will
be the fate of the children can be determined definitely only
after the records have been published of many children, whose
mothers were treated by this method, who have remained under
observation for a long period.

1 Centralbatt fiir Gynikologie, 1928.

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405

Spontaneous Rupture of a Pregnant Uterus, with Report
of a Case.

BY
H. D. De Sa, M.D., F.C.P.S.

Professor of Midwifery and Gynaecology, Gordonas Sunderas
Medical College, University of Bombay.

RUPTURE of a pregnant uterus during labour occurs in India
much oftener than it is generally believed. The following case
of spontaneous rupture during labour in an apparently normal
uterus was recently under my care.

Mrs. Z., aged 29, was due for her sixth confinement about the
end of October, 1933. At 12 midnight on the 24th of October
last the patient felt slight labour pains. It was too late to secure
a conveyance to take her to the hospital, which was Io miles
away. At about 4 a.m., having suddenly felt a strong pain, she
hurriedly dressed and sat on a chair, awaiting a taxi-cab to take
her to the hospital. While still sitting a second and stronger
pain expelled the child, which dropped on the floor. Fortun-
ately the chair was a low one and the umbilical cord and child
were not injured. Post-partum haemorrhage was profuse; the
patient fainted, and was laid on the floor and a doctor summoned.
On his arrival the doctor found the child lying between the legs
of the patient on one side and the placenta on the other, and
a beefy-looking mass was projecting from the vagina (Fig. 1).
He summoned a senior colleague, meanwhile treating the patient
for shock. The two doctors then pushed the projecting mass
up into the vagina, plugged the vagina and sent the patient in an
ambulance to my hospital.

On admission the patient was very pale; temperature 97°F.,
respiration 35 and pulse-rate 148. Two hours after admission
a rectal saline was administered, and when the general condition
of the patient had considerably improved, she was placed on a
table for examination. On removing the plug, the anterior lip
of the cervix, which was long, wide and oedematous, was seen
at the vaginal orifice, and there was a transverse tear two and
a half inches wide about two inches above its anterior lip in the
region of the anterior fornix. The upper edge of the tear was
not seen but could be felt high up behind the bladder. On
retracting the anterior vaginal wall a triangular raw surface was

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of the os. Succiform dilation of the anterior portion
of the lower uterine segment.

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SPONTANEOUS RUPTURE OF PREGNANT UTERUS

seen in front of the tear and behind the bladder. The lower
edge of the tear was badly bruised and ragged. The posterior
lip of the cervix was normal and the cervical canal admitted
three fingers (Fig. 2). As haemorrhage had stopped an attempt
was not made to repair the tear. A prolonged hot vaginal douch
of eusol was given, the raw surface and the cervix swabbed with
tincture of iodine and the patient was returned to her bed and
placed in Fowler’s position. The uterus was well contracted.
There was not any pain or tenderness on pressure or on pal-
pation of the pelvic region. The lateral fornices were normal.

The puerperium. In accordance with the routine of the
hospital the patient was treated as an infected case. The
temperature was raised for some days and the patient could not
pass urine naturally for a week. On the eighth day after admission,
- when the temperature was down, the patient was again exam-
ined. On introducing a Sim’s speculum and retracting the
vaginal wall, the anterior surface of the cervix below the tear
was seen to have sloughed. The sloughs extended to the anterior
lip (Fig. 3). Saline douches and free instillation of hydrogen
peroxide were ordered. By the fourteenth day the sloughs had
separated and the parts looked healthy and healing (Fig. 4).
The patient was discharged on the twentieth day after admission.

The history of the patient. Menstruation commenced at the
age of 13 and lasted for eight days once a month. There was
dysmenorrhoea from the onset of menstruation, which was
severe until the birth of her first child. She married at the age
of 19. The confinements of the patient were as follows :—

Confinement Date of Sex of
number confinement child

I 23 July 1925 Female
2 12 Sept. 1926 Female
3 31 Jan. 1928 Female
4 14 Sept. 1929 Male
5 31 Dec. 1930 Male
6 25 Oct. 1933 Female

All her labours were spontaneous and of short duration, the
first lasting six hours; the second occurred soon after her arrival
at the hospital; the third occurred too quickly for her to come to
the hospital. The fourth and fifth were also quick, but there
was just time for her to get to the hospital. The average weight
of her babies was five pounds.

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The health of the patient was, on the whole, good. She had
never been treated for any uterine complaint. Her weight was
four stones and seven pounds and her height four feet and seven
inches.

The urine was normal, and Khan’s test was negative. She
had all her confinements but tne last in my hospital.

Spontaneous rupture of the uterus during pregnancy or
labour, due to rapid stretching of the uterine wall or because the
uterus is diseased, is stated by textbooks to be very rare and
almost invariably due to traumatism or dystocia. The pre-
disposing causes of spontaneous ruptures are those which
produce weakening of the uterine wall, such as fatty or hyaline
degeneration of the muscle, syphilis, pressure necrosis during
labour, scars from previous operations or from puerperal compli-
cations. The site of the spontaneous ruptures is generally at the
lower segment of the uterus and the rupture is usually longi-
tudinal or oblique, and those in the fornix vaginae usually
transverse or even completely circular.

During the last 24 years those cases of rupture of the
uterus which I have seen at the Jemsetjee Jeejebhoy and
King Edward Memorial Hospitals and the Wadia Maternity
Hospital have been due either to obstructed labour or inju-
dicious manipulations. During the years 1928 to 1933 (i.e.
up to 31st October, 1933—five years and 10 months) 21,900
labour cases were treated at the Wadia Maternity Hospital, and
among these were nine cases of ruptured uterus. In almost all
of them the tear was at the lower segment and extended to the
broad ligament. All these cases were emergency cases. The
patients never attended the antenatal department. In my
private hospital I have not had a case of ruptured uterus for the
last 20 years. The vast majority of my patients are examined
and treated, if necessary, in the antenatal department.

An examination of the obstetric literature at my disposal has
failed to disclose any case of ruptured uterus similar to that of
Mrs. Z. I am inclined to think that the only condition that
could cause such a rupture as that of Mrs. Z’s without tearing
through the bladder or the broad ligaments is the so-called
sacciform dilatation of the anterior portion of the lower segment
due to a displacement of the cervix; and according to Edgar
the common, but not the sole, cause of this condition is obliquity
of the uterus. The same condition may be produced by over-
development of some portion of the anterior segment during the
latter part of pregnancy. Backward displacement is the most

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SPONTANEOUS RUPTURE OF PREGNANT UTERUS

frequent clinical variety, and is due either to anteversion or to
overdevelopment of the anterior portion of the lower uterine
segment (Fig. 5). Unfortunately I did not make a vaginal
examination on this patient when I first saw her in the eighth
month of pregnancy. Since the appearance and shape of the
uterus were normal and her previous confinements were normal,
except, for their short duration, there was not any indication for
a vaginal examination.

REFERENCE.
De Lee, Edgar, William Withrage. Bull. de la Soc. D’obstét. et de Gynécol.
de Paris; Journ. Obstet. and Gynaecol, Brit. Emp., Vol. xxxix, No. 4.

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>

An Unusual Case of Intestinal Obstruction

By N. M. MatHEson, F.R.C.S. (Eng.).
Central Middlesex County Hospital.

THE following case of strangulation of the small intestine appears
to be of interest on account of the unusual site of the obstruction.

Mrs. E. W., age 69 years, who had been suffering from
bronchitis for two weeks, was admitted to hospital complaining of
severe abdominal pains and complete constipation of three days’
duration. Incessant vomiting had occurred for 24 hours before
admission.

The patient, who was pale and anxious, had a subnormal
temperature and a pulse-rate of 104; her tongue was dry, brown,
and coated. There was great distension of the abdomen,
especially in the central portion, and tenderness was most marked
in the hypogastrium. The hernial orifices were normal and the
rectum ballooned and empty. Two enemata each gave a clear
result, although some flatus was passed after the second.

A diagnosis of obstruction of the small intestine was made and
an immediate operation performed under spinal anaesthesia
(percaine) .

After opening the abdomen by a right paramedian incision,
the peritoneal cavity was seen to be occupied by coils of distended
small intestine. On the right side of the pelvis a segment of the
ileum, almost six inches in length, situated about two feet from
its termination, was found to be strangulated in an opening in
the right broad ligament. This aperture was over one inch in
diameter, but there was not any sac. The round ligament in front
and the Fallopian tube and ligament of the ovary behind, being
tightly applied to the imprisoned loop, indented the walls of the
oedematous bowel.

The gut, which was reduced after drawing the Fallopian tube
and ovarian ligament backwards, showed intense congestion. It
appeared viable, so was placed in the pelvis and the edges of the
gap were united with catgut sutures. Vigorous peristalsis was
observed from the beginning of the operation, the release of the
intestine being almost immediately followed by a copious action
of the bowel.

The patient made a good immediate recovery, but died in six

410

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Uterus viewed from the front—showing the ileum adherent to site
of opening in the right broad ligament.

UNUSUAL CASE OF INTESTINAL OBSTRUCTION

weeks’ time from pulmonary congestion consequent upon
auricular fibrillation.

An examination of the abdomen was made after death when
the ileum was found to be adherent to the line of closure of the
aperture in the broad ligament. There was not, however, any
further sign of obstruction by these adhesions.

Herniation of the intestine through deficiencies in the broad
ligaments has seldom been described. Although Barnard’
referred to such a condition, the two cases reported by C. H.
Fagge’ appear to be the first recorded. In each of these the bowel
occupied a peritoneal fossa.

Subsequently Pidcock* described a case in which the middle
two inches of the round ligament were quite free from the broad
ligament and bridged over and strangulated the subjacent coils of
small intestine.

Barr* had a patient in whom strangulation occurred through a
definite aperture, and Janes’ has added two more, in both of
whom an opening, without any pouch, was present. The drawing
depicting the condition found by Janes at the operation on his
second patient bears much resemblance to the operative findings
in the case here recorded.

Previous writers have commented upon the absence of inflam-
matory changes in the pelvis, and have mentioned the possible
relation to pregnancy. Most of the patients have been parous,
Pidcock’s patient being admitted 14 days after a normal labour.

-Of the seven cases to which I can find references, the strangu-
lation involved the small intestine in all, and occurred on the left
side in five. In two, at a subsequent operation, adhesions were
noted between the ileum and the original incision. The accom-
panying figure of the uterus, viewed from the front, shows the
ileum adherent to the line of closure of the opening in the broad
ligament.

REFERENCES.
. Barnard, H. L. Contributions to Abdominal Surgery, 1910, p. 216.
. Fagge, C. H. British Journal Surgery. 1917-18, v, 694.
. Pidcock, B. H. British Medical Journal, 1924, i, 369.
. Barr, H. A. (Quoted by Janes.) Med. Record and Amn., 1920-21,
xiv, §.
. Janes: R. British Journal Surgery, 1929, xvii, 333.

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Uterus Bicornis Unicollis: Atresia of the Internal Os:
Retained Menses: Hysterectomy

By A. H. Coteman, O.B.E., F.R.C.S., Edinburgh.

Honorary Surgeon, Carnarvonshire and Anglesey Infirmary,
Bangor.

ON the 16th of October, 1933, Mrs. E., 29 years of age, was sent
to me by her family doctor, Dr. W. Thomas of Conway. She
complained of attacks of pain, off and on for the last four years,
in the lower part of her abdomen. The attacks varied in
frequency, severity and duration, and the pain was always
colicky in character and was sometimes accompanied by vomit-
ing. In the intervals between the attacks she states that she felt
well, and was able to carry out her household duties.

The patient was a well-nourished, healthy looking woman,
and was married II years ago at the age of 18. She has not
had any children and has never menstruated, marital rela-
tions have always been normal, and there has not been any
unhappiness in her married life. She has seven sisiers and there
is not any history of menstrual irregularity or abnormality in
any of them. Constipation has been a prominent feature for
several years.

The patient was confident that the attacks of pain did not
occur at regular monthly intervals, but assured me that they
were quite irregular, sometimes with only a few days’ interval.

On 19th October, 1933, an examination under gas-oxygen-
ether anaesthesia was made. The external genitalia‘and vagina
were normal. The cervix was normal in appearance, and
the cervical canal admitted a sound for a distance of r inch. The
body of the uterus was about the size of a cricket-ball and was
normal in position. An indefinite mass could be felt through the
fornices in the pouch of Douglas.

The abdomen was opened by a median incision below the
umbilicus. The transverse colon and the great omentum were
adherent to the anterior abdominal wall, and a large band
extended from the right border of the omentum to a caseous
gland at the root of the mesentery. This band was divided and
the caseous gland removed. All the pelvic organs were covered
with film-like adhesions which were easily separated. The pelvis

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UTERUS BICORNIS UNICOLLIS, ETC.

contained some traces of old blood and the pelvic colon was
adherent to the posterior surface of the uterus. The uterus and
appendages having been freed, total hysterectomy was _per-
formed. The ovaries, which were scarred and contained
numerous small cysts, were removed at the same time.

The patient made an uninterrupted recovery and was dis-
charged from the Nursing Home three weeks after the operation.

An examination of the specimen (see photograph) shows
uterus, both Fallopian tubes, and both ovaries. The cervix uteri
is single and patent as far as the internal os. The body is a
bicornute uterus and each horn is approximately the same size
and contained old blood. There is complete atresia of both
horns at the level of the internal os. Both Fallopian tubes are
dilated, tortuous and contain old blood.

This casei would appear to be of interest because I cannot find
any reference to a similar case in the literature. Malformations of
the uterus result from anomalies in the development of the
Miillerian ducts. Fusion takes place over those portions of the
ducts which form the uterus and vagina, and at first the fused
uterus and vagina are separated by a septum. Absorption of this
septum occurs from the vulva to the fundus uteri and, according
to the degree of absorption of the septum, various abnor-
malities may be found. A localized stenosis, or imperforation, at
any point in the uterine or vaginal canal is a complication caused
by defective resorption or incomplete cavity formation in the
primitive Miillerian duct.

This case is of interest because both Miillerian ducts appar-
ently developed at a similar rate, incomplete canalization
ocurred in each duct at precisely the same point, and this was
at the point at which absorption of the septum ceased.

The patient was again examined on January roth, 1934,
and then expressed herself as being very well. There had not
been any return of the pain, and the symptoms of the artificial
menopause have not been severe.

413
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Abortion and Sterility

By PRoFEssor L. I. BUBLITSCHENKO,

Obstetric and Gynaecological Scientific Institute (Director
Podzoroff), Leningrad.

A GREAT number of papers has been written on the subject of
abortion; the sequelae of the somatic, nervous, and even
psychological, traumata to the sexual organs associated with
artificial abortion are many and varied. These sequelae were
fully discussed by Meyer in a paper read before the Ukraina
meeting in Kiew' in which he took a gloomy view of the results
of abortion. Nevertheless the practising gynaecologist is well
aware that thousands of abortions procured monthly and
frequent abortions occurring in the same woman are not followed
by unpleasant consequences.

The purpose of this paper is to report the causes of sterility in
women who failed to become pregnant after having aborted, the
study being clinical and having regard to constitutional peculi-
arities. The material consisted of 200 women who were
examined and questioned with regard to age, onset and character
of menstruation, intensity of libido sexualis, duration of
marriage, fecundity of the mother, constitution of the patient
according to my scheme (in which the size and width of the
chest, shoulders and hips, and the length of the body and the
extremities are measured), number and issue of previous preg-
nancies, date of last abortion and the circumstances in which it
was performed, the most important symptoms and the condi-
tion of the sexual organs at. the time of examination.

These patients did not come for consultation until after more
or less prolonged treatment by other surgeons for sterility follow-
ing abortion. The duration of the sterility varied greatly: 18
women, or nine per cent, were sterile for more than two years;
36, or 18 per cent, for three years; 24, or 12 per cent, for four
years; 82, or 41 per cent, from five years to 10 years; 34, or 17 per
cent, from II to 15 years; and six, or three per cent for more than
15 years. Of all the women examined, 38, or 19 per cent, were
married for three to five years; 83, or four per cent, from six to
10 years} 72, or 30 per cent, from II to 20 years; and seven, or 3.5
per cent, more than 20 years. Their ages were as follows: 33, or
16.5 per cent, 20 to 25 years; 80, or 40 per cent, 26 to 30 years;

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ABORTION AND STERILITY

59, or 29.5 per cent, 31 to 35 years; 21, or.10.5 per cent, 30 to 40
years; and seven, or 3.5 per cent, more than 40 years.

The majority, 56.5 per cent, became sterile before they were
30 years old and 29.5 per cent between the ages of 31 and 35
years. Thus 86 per cent were rendered sterile by abortion at their
most productive period. These gloomy figures suggested that an
analysis of the direct causes of the sterility might be of value and
suggest suitable prophylactic measures. As such could be taken :
(x) Obvious inflammatory conditions, the result of abortion or of
pre-existing conditions such as endo-cervicitis and gonorrhoea
being lit up by abortion. (2) Other changes, resulting from inflam-
mation of the Fallopian tubes, uterus and ovaries but not
detected by a simple vaginal examination. (3) The depression of
fertility resulting from traumata, particularly affecting constitu-
tionally defective women.

Analysing our material along these lines we found that imme-
diate hereditary influences do not play any part in sterility, as the
mothers of the patients were for the most part more than usually
fertile. This can be seen from the following table if it be remem-
bered that some died at an early age while others had abortions
in addition to full-time pregnancies.

Number of pregnancies .. Ito3 4to6 7tog Ioto12 13t015 15
Number of mothers ... 4 19 38 18 4

Nevertheless, the following case suggests that the influence
of heredity cannot be altogether excluded. The patient, T.,
aetat 30, was sterile for four years following an abortion.
Amenorrhoea persisted for two years after a second curettage.
Her mother had only four children and the menopause occurred
at the age of 35. The patient herself is of an asthenic constitution.
Menstruation commenced when she was 18 years old, was scanty
and lasted for only two or three days. She had no libido
sexualis.

Of the series under review 90 women, or 45 per cent, were
pregnant once; 47, or 25 per cent, twice; 15, or 7.5 per cent, on
three occasions; and 30, or 15 per cent, on more than three
occasions. In such cases it might be imagined that the repro-
ductive function had become exhausted, but the ages of. the
patients who had several pregnancies do not offer any support for
such a supposition. Twelve patients were from 20 to 25 years old,
seven from 26 to 30 years old, eight from 31 to 35'years of age,
and only three were between the ages of 36 and 40 when their last
pregnancies occurred. Previous full-time deliveries do not

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JOURNAL OF OBSTETRICS AND GYNAECOLOGY

prevent subsequent abortions from causing sterility, for 48
women, or 24 per cent, had had children prior to the abortions
which rendered them sterile. It is interesting to note that there
were cases of sterility occurring after the first delivery at term at
a very early age, five women being less than 25, one 30 and
another 35 years of age. In three of these women preg-
nancy and delivery were normal and the only abnormality
found on examination was retroflexion of the uterus. One
patient was confined six years ago and, although there were not
any complications at, or after, delivery, she has not since become
pregnant. She is of an asthenic constitution, had none of the
diseases of childhood, but 10 years ago she had typhoid fever,
followed soon after by paratyphoid fever. Menstruatio exanthe-
maticus started when she was 16 years old, and became estab-
lished at once; its duration was four or five days at intervals of
28 days; the flow was scanty and was associated with pain, even
after her confinement.

In 114 cases, or 57 per cent of the patients, chronic inflamma-
tory disease was present and could be taken as the cause of the
sterility. In 91 patients (45.5 per cent) disease of the adnexa
was present, associated in three cases with sacto-salpinx, in two
cases with vulvitis, in 13 with endo-cervicitis or endometritis, and
in six cases with erosion of the cervix. In 10 cases (five per
cent) we could detect the presence of fibrous bundles and in two
cases cyst-like formations.

Inflammation of adnexa
Inflammation of adnexa and erosion of the cervix
Inflammation of adnexa and vulvitis
Inflammation of adnexa and endometritis
Inflammation of adnexa and gonorrhoea

Metritis and endometritis

Endo-cervicitis

Pelvic abscess

Fibrous bundles

Cyst

Leal

In 56 cases the inflammatory disease developed immediately
after the abortion and in 12 cases, six per cent, was complicated
with haemorrhage. In the remaining cases it occurred at a later
date, apparently apart from infection during abortion, and in
some cases after a long time. (In three cases one year, in three
cases two years, in one case three years, and in one case four
years after the abortion). In 25 i a more or less prolonged

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ABORTION AND STERILITY

haemorrhage followed the abortion, but the patients did not
notice any rise of temperature. It follows that haemorrhage after
abortion, even in the absence of inflammatory signs, is a very
important aetiological factor in the sterility which follows abor-
tion. Apparently the remaining particles of the decidual
membrane hinder the normal regeneration of the mucosa.
Although this is not detected by clinical examination, neverthe-
less the endometrium ceases to be a suitable nidus for the
implantation of the ovum and the woman is rendered sterile.

Inflammation occurring shortly after abortion may be com-
plicated by infection if it be prolonged, particularly if procured
by the injection of tincture of iodine through a catheter, or if
curettage has to be repeated. Such manoeuvres aggravated the
abortion in 29 cases, in 11 of which it was induced by a catheter
(in two cases by the patient herself), in seven cases by injection
of tincture of iodine, in three cases curettage was performed
frequently, while in eight cases the abortion was spontaneous but
prolonged. In some cases the infection did not appear to have
been carried from without but to have pre-existed in the genital
passages. One cannot say how often such cases were encoun-
tered, but, if those abortions which were procured by a midwife
or the patient herself be excluded it must be assumed that the
infection must have been in the genital passages before the
abortion, since the majority of the operations were performed by
a surgeon in a clinic.

In this connexion inflammation of the adnexa and endo-
cervicitis were regarded with particular suspicion. The presence
of infection before abortion was certain in 10 patients, of whom
three had gonorrhoea, while three suffered from inflammation of
the adnexa and four from leucorrhoea long before the abortion
occurred. In a series of cases in which inflammation of the
adnexa and of the pelvic peritoneum were the direct causes of
sterility, a direct connexion between these conditions and the
abortion could not be traced. In many cases the inflammatory
disease occurred long after the abortion and it would appear that
the sterility was directly due to it and not to the abortion.

It is more difficult to establish the connexion between sterility
and abortion when acute inflammatory disease cannot be
established to have occurred. The sterility occurred after the
abortion, whether due to blockage of the Fallopian tubes,
changes in the endometrium or disturbance of the hormonal
function of the ovaries. The diagnosis of the direct causes of
sterility in these cases is, needless to say, very difficult. In many
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JOURNAL OF OBSTETRICS AND GYNAECOLOGY

cases, for example, it was said to be due to blocked Fallopian
tubes. Does it, however, mean that, in those cases in which the
Fallopian tubes were patent and inflammatory changes in the
uterus were absent, there were, nevertheless, changes which pre-
vented the implantation of the ovum but which could not be
detected by clinical examination? It follows that not only the
study of the direct causes of the sterility but also the constitu-
tional peculiarities of such women who are sterile but present no
changes in the genitalia which can be detected clinically, are of
great importance. The small amount of material at my disposal
led me to believe that those women in whom inflammatory
diseases could not be detected were deficient constitutionally.
Almost every woman in this group presented one or other of the
common defects in morphology, constitution, structure or func-
tion of the sexual organs. Ten of this group (11.6 per cent) had
fibromyomata. Not all constitutional defects find their expres-
sion in morphological peculiarities. It is true that of the 86
women who had inflammatory changes in the adnexa those of the
asthenic type predominated (59.3 per cent). There were also 9.3
per cent of the hypoplastic type, but 31.3 per cent were women
of the pyknic type, in some cases shaegshy pronounced, and with-
out obvious defects of the genital organs. Two women became
markedly more obese after abortion. In some cases deficiencies
in uterine structure were noted and included 13 cases (15.5 per
cent) of pathological anteflexion and three cases of retroflexion,
while in 18 other cases (21.42 per cent) more or less pronounced
signs that the genital organs were imperfectly developed were
noted. Functional defects were frequently present, libido
sexualis being markedly reduced in 22 cases (26.2 per cent) and
completely absent in 19 cases (22.6 per cent). In one case the
libido was reduced and in three cases lost, immediately after the
abortion occurred. It is interesting, however, to observe that in
one case libido sexualis was experienced only after curettage.
Turning to the menstrual function, different changes were
noted. In four cases (4.7 per cent) menstruation became
retarded after the nineteenth year, in five irregular, and in seven
considerably delayed. In five of the patients delay in menstrua-
tion followed the abortion. In 14 (16.6 per cent) cases the flow
was scanty (in eight cases or 9.3 per cent the reduction in the
flow followed the abortion). Seven patients (8.1 per cent)
suffered from amenorrhoea for from six to 18 months, while in
two cases the climacteric occurred prematurely, one patient
being 26 and the other 36 years of age. Thus changes in the
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ABORTION AND STERILITY

menstrual function were noted in 52 cases (61.9 per cent). It
must be admitted that similar changes occur after normal con-
finements. In the case of one patient, K., whose mother bore
11 children, menstruation ceased and the libido sexualis dis-
appeared, although before delivery it was sharply pronounced.
She is of the asthenic type, and had typhoid fever during child-
hood. Menstruatio exanthematicus commenced when she was 18
years old, lasted from three to six days, and appeared at intervals
of from three to four months until marriage, after which it was
regular. Delivery was normal, she suckled her child for one
year, and milk is still present in the breasts.

This analysis of the causes of sterility following abortion
therefore shows that it chiefly results from inflammatory disease,
in most cases being caused by infection during abortion (28 per
cent). Although gonococci were demonstrated in only a few
cases, the clinical picture (infection of both Fallopian tubes or
of the cervix uteri) demonstrated in most cases the gonorrhoeal
nature of the disease. Moreover, since in most cases the abor-
tions were procured by surgeons in a clinic (only 20 of the 114
women with inflammatory disease being treated by midwives),
septic infection was very improbable. In those women in whom
inflammatory disease could’ be excluded the sterility was due to
constitutional defects.

Clearly pronounced signs of poor development of the sexual
organs were noted in 21.4 per cent and pathological anteflexion
in 15.5 per cent of the cases. In this group we include fibro-
myomata (11.6 per cent), their development being the result of
constitutional defects of the vascular system and also of consti-
tutional defects in the genital organs, e.g. pathological ante-
flexion. Constitutional defects are often associated with func-
tional defects such as reduction or absence of the libido sexualis,
and disturbance of the menstrual function which denote hormonal
deficiency. Menstruation may be delayed and scanty, and
amenorrhoea or even a premature climacteric may follow
abortion.

REFERENCE.
1. Mayer, Zentralb. {f. Gyndkol., 1932, xlvi, p. 2753.

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419

Hydatidiform Mole in a Young Primigravida.

BY
PROBODH CHANDRA Das, M.B. (Calcutta).

L.D., a Hindu, Bengali, primigravida, aged 16 years, consulted
me on 16th September 1931. The history she gave was as
follows. Menstruation commenced at the age of 16 and had
been regular every 28 days, lasting three or four days, till 16
weeks previously, when it failed to appear. For the last four
days there had been, on and off, vaginal haemorrhage.

The patient was well nourished. The fundus uteri was at the
level of the umbilicus, the foetal parts could not be felt and foetal
heart sounds were not audible. On vaginal examination the
cervix felt soft and the external os was closed. There was
bright red blood on the examining finger. The patient was kept
in bed. Next day, for the first time, she complained of slight
intermittent pain in the lower abdomen, and was given a sedative
mixture. For the next two days there was only slight bleeding
and the pain ceased. On September 18th the bleeding increased
and the pain recurred; the cervix still remained closed. Next
morning, the pain and bleeding having increased, the patient
was again examined vaginally, and the cervical canal admitted
the tip of the index finger, when a few vesicles were expelled.
Under chloroform the uterus was explored and a hydatidiform
mole was evacuated, after which the uterus was plugged and
one cubic centimetre of infundin was injected. The patient made
an uneventful recovery.

Although a hydatidiform mole is stated to be comparatively
rare in primigravidae, Kedarnath Das’ has ‘‘observed quite a
number of cases in young primigravidae.’’ He recorded a case*
of hydatidiform mole in a young Bengali girl aged 13. Both
Das and Green-Armytage think that hydatidiform mole occurs
much more frequently in India than is generally supposed.
According to Green-Armytage,* it occurs once in every 230 preg-
nancies in the Eden Hospital.

The case recorded is peculiar in that the colour of the blood
was bright red, and not that of red currant juice, while the
consistence of the uterus was not doughy as is usually the case.

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HYDATIDIFORM MOLE IN A PRIMIGRAVIDA

REFERENCES.

. Das, Kedarnath. ‘‘Handbook of Obstetrics,’’ 2nd Ed., 1918, Butter-
worth & Co. (India) Ltd.

. Idem. “‘Vesicular Mole (A Monograph),’’ 1893.
. Green-Armytage, V. B., and P. C. Dutta. ‘‘Textbook ot Midwifery in
the Tropics,’’ 1933, The Book Co. Ltd., Calcutta.

—
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ey
are.

Obituary

ADOLPHE PINARD
(1844—1934).

OBSTETRIC medicine has lost one of its greatest heroes by the
death of Adolphe Pinard in his ninetieth year. The eldest son of
a family in the Champagne country, he was born in 1844 at
Méry-sur-Seine in the Department of l’Aube. He went at an
early age to Paris and, having insufficient means to prosecute
his medical studies, he became apprenticed to a chemist, and
was thus enabled out of his slender salary to support himself and
render aid to his brothers. He was a student of medicine at the
time of the Franco-German War, and served in the advanced
posts around Paris. He was appointed an interne des hépitaux
in 1871. In 1873 he served as interne to Stéphane Tarnier. In
1874 he obtained the doctorate by his thesis on ‘‘Pelvimétrie et
Pelvigraphie des Bassins Viciés,’’ and in 1878 became professeur
agrégé at the Faculté de Médecine. At this time was created a
class of special obstetricians, ‘‘les accoucheurs des hépitaux,’’
and Pinard was the first to be appointed.

After several years at the Lariboisiére hospital Pinard was
summoned to direct the Clinique Baudelocque, which, under his
direction, soon obtained a world-wide fame.

In 1878 Pinard published his ‘‘Traité de Palper Abdominal’”’
and ‘“‘Version par Manoeuvres Externes.’’ These excellent
treatises had an important influence on obstetric practice and
gave evidence of the great clinical acumen of the author. Always
tempering his scientific zeal with a humane regard for the welfare
of the mother and infant, he was delighted when he could
justifiably exclaim ‘“‘la basiotripsie a vécu,’’ as a result of the
improvements in symphysiotomy, of which he was an early
advocate. Also, in the interest of the child, he thought that
difficult extraction with the forceps and induction of premature
labour should be abandoned in favour of symphysiotomy, an
operation since displaced by the superior results of Caesarean
section.

In his clinic he was the grand maitre, with a dignified presence
and a good voice which gave utterance to incisive and
epigrammatic sayings which much impressed his pupils, who

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tried to copy his style. I remember the smile of the master, at
the congress at Moscow, when his favourite pupil Varnier, in
dramatically describing the culbute of the infant, cried out
“Brup!’’ Pinard devoted the latter years of his life to the
welfare of infants, becoming a puériculteur; and one of the last
functions he attended was the opening of the Ecole de Puéri-
culture, when he received the cross of grand officier de la légion
d’ honneur.

The loss of his son, killed in the World War, was a great blow,
stoically borne. He was for eight years a député for Paris and
was the doyen of the Chambre.

Pinard enjoyed splendid health, for which he always thanked
his parents. By their side he rests in the village where he was
born.

All those who knew him will retain happy memory of the
master, so zealous for the welfare of his country, its mothers
and their babes, a great teacher, a great obstetrician, a great
gentleman.

H.R.S.

British Gynaecological Visiting Society.

The Society to the number of 26 visited Holland between April
2gth and May 4th, making Amsterdam its headquarters. A most
excellent and instructive programme of work had been arranged
by Professor van Rooy.

On Sunday morning, April 29th, there was a trip to Meerrust
to see the famous tulip farms, lunch being taken in an old inn
among the tulips.

On Monday morning, May Ist, Professor van Rooy gave a
lecture and demonstrations in the University Obstetrical and
Gynaecological Clinic, of which he is the Director. In the after-
noon the members were conducted round the Clinic, and its
organization and administration were explained. A visit to the
Municipal Health Department followed, where the Director, Dr.
Heyermans, demonstrated the organization of the Antenatal, Post-
natal, and Child Welfare Clinics. In the evening the Society was
entertained to dinner in the country by Professor van Rooy at the
“Witte Bergen’’ Restaurant, Laren.

On Tuesday, May 1st, the Obstetrical and Gynaecological
Clinic was again visited, and Professor van Rooy pertormed
several operations. This was followed by a lecture by Dr.
Salomonson on the ‘‘Organization of the Maternity Services in
Holland.’’ The party then left by motor coach for a reception
by the Mayor of Edam and lunch at the Hotel Spaander
at Volendam, on the edge of the Zuyder Zee. Later in the after-
noon the Rijksmuseum was visited, the party being conducted
by the Assistant Director of the Gallery. In the evening the
Society held its official dinner at the Carlton Hotel and was
honoured by the presence as guests of Professor van Rooy,
Professor De Snoo, Professor Noyons, Professor De Vries, Dr.
Wesselink, Dr. Salomonson, Dr. Heyermans, and others.

On Wednesday, May 2nd, the party left for Utrecht and visited
the Obstetrical and Gynaecological Clinic, where Professor De
Snoo gave demonstrations and performed operations. In the
afternoon a visit was paid to the New Physiological Insti-
tute, built by a Rockefeller grant, where Professor Noyons had
arranged a magnificent demonstration of experimental work.

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On Thursday, May 3rd, the party left by train for Rotterdam,
and visited the special School for Midwives, where the Director,
Dr. Wesselink, demonstrated the work of the School and gave a
most valuable lecture on ‘‘The Training and Organization of Mid-
wives in Holland.’’ The party left Rotterdam in the evening after
a very instructive visit, in which our kind and generous Dutch
colleagues did everything possible to help and entertain the
Society.

2
?
oy
425

British College of Obstetricians and Gynaecologists.

THE Quarterly Meeting of the Council was held on Friday,
April 27th, 1934, in the College House, with the President,
Dr. J. S. Fairbairn in the Chair.

The following were elected to the Membership of the
College : —

Agnes Marshall Cowan - - = Manchuria
Charles Leopold Granville Chapman - — Grimsby

The President formally admitted to the Fellowship of the
College : —

Lieut.-Col. Duncan Coutts - India
Lieut.-Col. Peter Fleming Gow - India
Professor Gordon Grant -~ - Johannesburg
Lieut.-Col. Sydney Nuttall Hayes India

Major Maurice Lawrence Treston India

James Hayward Willett - - Liverpool

and to the Membership : —

Margaret Emily Anderson

Gavin Stiell Brown

John Lloyd Davies

Charlotte Ann Douglas

Gwyneth Griffith

Kathleen Marguerite Douglas Harding
Jocelyn Adelaide Medway Moore *
Percy Peltz

John Marshall Scott

Arthur Joseph Wrigley

A Silver Mace was presented to the College by the Gynaeco-
logical Club.

The Annual General Meeting was held in the College House
on Friday, April 27th, 1934, with the President, Dr. J. S.
Fairbairn in the Chair, and 38 Fellows and Members present.

The annual report of the Council and Financial Statement
were adpoted.

Messrs. Barton, Mahew & Co. were elected Auditors for the
ensuing year.

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HOSPITAL REPORTS.

THE MEDICAL REPORT OF THE GLASGOW ROYAL MATERNITY
AND WOMEN’S HOSPITAL FOR THE YEAR 1932

THis Report follows very closely the lines of previous Reports for this
Hospital, and a cursory glance makes it obvious what a wealth of material
is dealt with at Glasgow.

A closer scrutiny, however, reveals that Glasgow is apparently very
jealous of this fact, so much so that the Report magnifies and exaggerates
the actual numbers of abnormalities. The most striking example is the
table labelled ‘‘Breech.’” This states that there were 308 cases of breech
presentation, 249 being in patients who had been under antenatal super-
vision. A careful analysis of this table reveals the fact that nearly 100
of those cases in which the diagnosis of breech was made in the ante-
natal department were vertex presentations at delivery—sometimes,
apparently, after external version had been performed. Twelve were
Caesarean sections. In the various tables in which details of Caesarean
sections are given, we can find only three cases in the ‘‘Contracted Pelvis’’
table, in which it is mentioned that the foetus was presenting by the breech.
No explanation is offered as to the indication for Caesarean section in the
remaining I1 cases in which the breech was presenting. In the ‘‘Placenta
Praevia’’ table there is not any mention of the presentation—a point
which we consider of great importance in arriving at the decision as to the
best method of treating placenta praevia.

There were 71 stillbirths among the breech deliveries, so that the
mortality rate is 34.8 per cent. The neo-natal deaths are not recorded. In
our experience there is usually a considerable neo-natal death-rate following
breech delivery, and we feel sure that there was at least one in this series,
as we notice that when perforation of the after-coming head was performed
the child was born alive, and we feel sure it cannot have lived long.

In the table dealing with transverse lie—Glasgow still persists in calling
it transverse presentation—there are four cases which undergo spontaneous
version, one of which is undelivered! This again is an example of swelling
the table. Surely it is obvious that a case such as Register Number 73,
found to be a transverse lie at 32 weeks gestation, which undergoes spon-
taneous version and is delivered as a normal vertex nine weeks later, is not
of interest as regards the treatment of transverse lie!

It is almost a tradition that Glasgow is the home of contracted pelvis.
This being so, it strikes us as being strange that contracted pelvis should
be diagnosed in cases such as Register Numbers 2213, 3143, and 3686.
Number 2213 had a labour lasting four hours, resulting in a spontaneous
delivery of a living child weighing 1634 pounds. Number 3143 had a labour

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JOURNAL OF OBSTETRICS AND GYNAECOLOGY

lasting two and three-quarter hours, which resulted in the spontaneous
delivery of a living child weighing 1234 pounds. In the ‘‘Remarks’’ column
she had a ‘‘syncopal attack at delivery.’’ We are not surprised! Number
3686, after a labour lasting 3 hours and 40 minutes, delivered herself of a
living child weighing 11 pounds. We should not class any of these three
cases as contracted pelvis.

We still miss a glossary. Last year we asked the meaning of B.B.O.
We are still left wondering. We notice this year that Register Number
4029, in the table of ‘‘Heart Disease,’’ had this method of delivery, so our
guess last year that it meant ‘‘born before. the onset of eclamptic fits’’ is
wrong.

The most interesting table is the special one on page 104, ‘‘Failed
Forceps.’’ It is interesting because in ‘‘Category A’’—patients who are
under antenatal supervision and who are presumably treated by the hospital
staff—the number of cases is 18, and the ‘‘Remarks’’ column is most
bewildering. Exactly half the cases of failure to deliver is stated to be due
to the fact that the os was not fully dilated! and one-third of these eventually
had spontaneous delivery. Among the ‘‘Category B’’ patients we notice
an interesting case of craniotomy in a case of anencephaly. This must be a
very interesting procedure. We notice two cases in which death is ascribed
to delayed chloroform poisoning. In both cases there appears to have been
a great deal of trauma during delivery, and both are stated to have had
uterine sepsis afterwards. We have often wondered how many of the
alleged delayed chloroform poisoning are really due to trauma and sepsis.
In both these cases it certainly looks possible.

The report is full of interest, but the very scanty letterpress makes it
dull reading. Many of the tables are so large that we have not analysed
them in detail. There are very few cross-references, which makes it difficult
to trace the full history of any given case. A most interesting series of
cases of lower segment Caesarean section without any maternal mortality
is worthy of especial notice.

Louis Rivett.

THE MEDICAL REPORT OF THE LEEDS MATERNITY HOSPITAL
FOR THE YEAR 1932

TuIs Report is of outstanding merit. It is more than a mere statistical
account of the year’s work: indeed it contains few large tables and no
complex ones. Nevertheless, it clearly states the opinions that the hospital
staff formed from the cases treated, and the reader is able to follow the
reasoning which lay behind the choice of method. This is made possible
by the numerous excellent clinical histories in which the case is discussed as
well as described. Some of these are very frank; mistakes are admitted,
and even fortunate escapes are acknowledged as such. For instance, at the
end of one report we read, ‘‘Although this case came to a successful issue it
was thought afterwards that the best treatment would have been a set
Caesarean section.”’

The sections on induction of labour, version, hydramnios, injection of

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the umbilical vein, and injection of novocain into the cervix are of special
interest. Equally important from another standpoint are the comments on
cases admitted after unsuccessful attempts to deliver with the forceps.
Thirteen such cases are detailed ‘‘as this complication of labour does not
seem to become less common in its occurrence.”’

For these reasons the Report is of great value. It is, moreover, very
easy to read, as the diction throughout is pleasing and fluent. Other
Registrars would do well to study and imitate it.

THE REPORT OF THE PRINCESS MARY MATERNITY HOSPITAL,
NEWCASTLE-UPON-TYNE, FOR THE YEAR 1932.

THE author of this Report has compiled many very elaborate tables, and
has kept them remarkably free from error. Yet in spite of this the Report,
as a whole, is disappointing.

Almost certainly the fault does not lie solely with the Registrar, but must
be attributed in large measure to the records on which he had to work. For
example, an imposing table promises much detailed information on cases of
albuminuria and eclampsia, but numerous blank spaces reveal the fact that
fhe blood-pressure is often unrecorded. Similarly, in many cases of con-
tracted pelvis, even when Caesarean section was performed for this
indication, pelvic measurements are not given. As if to compensate for this
omission the length of the external conjugate diameter is entered in several of
the others, although it is difficult to see what use can have been made of this
observation. Every one knows how impossible it is to measure this diameter
with any degree of accuracy, yet here it is stated with extreme exactitude.
A mere glance at the corresponding measurements of the true conjugate
diameter in this very list shows how misleading and valueless the external
measurement can be. Here are some of the readings which illustrate this
point :—

External conjugate True conjugate
534 inches 3'4 inches
7% 24
74»

Many of the tables are, however, of great interest, notably those dealing
with stillbirth, neo-natal death, and birth-injury.

The most unsatisfactory feature of the Report is the careless, clumsy
phraseology of the case-histories. Many examples could be quoted, but the
following will suffice: ‘“‘Admitted after failure of forceps delivery outside,’’
‘‘Admitted after failed delivery by forceps outside,’’ ‘‘a forceps delivery
was performed,’ ‘‘following expulsion of the placenta a severe degree of
uterine atonia followed.’’ Even more regrettable is the flippant statement,
“Three hours after admission there was a spontaneous expulsion of a still-
born foetus and the patient promptly expired.’’ The proof-reading has
also been careless, and a number of obvious mistakes in the letterpress have
escaped detection.

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JOURNAL OF OBSTETRICS AND GYNAECOLOGY

THE MEDICAL REPORT OF THE BRITISH HOSPITAL FOR
MOTHERS AND BABIES, WOOLWICH, FOR THE YEAR 1932

In its present form this Report is not of any use to any one. The total
number of patients is small, complications are few, and while there must
have been ample time for the thorough investigation of such abnormalities
as did occur, the Report does not give any details of them. Only two
mothers died: one of these was delivered by Caesarean section on account
of multiple fibroids, the other was an eclamptic. Yet it is stated in
Table IV, in which this case of eclampsia appears, that all the mothers did
well. Several of the other tables contain discrepancies almost as obvious. ..
According to the Report, there were 114 cases of contracted pelivs.
these only one required Caesarean section. It would be interesting to know

therefore, if the degree of contraction was almost invariably slight or if most |

of the children were abnormally small. But we are not informed. The
weight of the children is entered in only four cases in the whole Report.
Regarding the pelvic measurements we are equally in the dark; the diagonal
conjugate is mentioned once, the true conjugate never, and the cases are
actually divided into three groups according to the measurement of the
external conjugate. Our opinion of the value of this diameter as an index
of the size of the true pelvis need not be repeated.

It is to be hoped that next year a reasonably detailed account of the

work of this hospital will be presented.

‘

THE REPORT OF THE MATERNITY DEPARTMENT OF THE
JESSOP HOSPITAL FOR WOMEN, SHEFFIELD,
FOR THE YEAR 1932

THE actual printing of this Report has been done by craftsmen who take a

pride in their work; the type is beautifully clear, the spacing excellent, a1
the tables are well set.

The subject matter has been arranged with care, and other Registrars
will be interested to learn that ‘‘last year it was decided to base the Report
on discharges instead of on admissions as heretofore. This plan was found
to work very well and has been adhered to this year.’’ We would also direct
the attention of those compiling similar reports to the table giving the
reasons for which all the patients treated in the antenatal wards were
admitted. Sometimes it is difficult, and occasionally it is impossible, to
unearth this information from the various tables through which it is
scattered, and it is a convenience to have it collected in this way.

Throughout the Report there is repeated evidence of detailed clinical
observation, most strikingly illustrated perhaps in connexion with twin
pregnancy and breech presentation. The summary of breech deliveries and
the method of grouping these cases in the extended table are very good. It
is the more surprising, therefore, that so little is said about the toxaemias
of pregnancy and nothing at all about post-partum haemorrhage. Again,
there were 61 cases of contracted pelvis, but apart from a list showing their
numerical distribution among the several types of contraction, the Report
does not give any particulars regarding them. By searching through the

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other tables we can discover how the majority of these cases were treated,
but that is all. Incidentally, we observe that in the complete enumeration
five cases are described as examples of the rachitic flat pelvis, whereas six
cases are so designated among the patients delivered by Caesarean section.
A slip is also apparent on page eight, where the text differs from the table
regarding the number of occipito-posterior positions. There is only one
other inaccuracy worth mentioning. We read that 15 children delivered by
version were stillborn, ‘‘thus showing a foetal mortality for this operation
of 75 per cent,’’ but the death of the foetus in most of these cases is just as
likely to have been caused by the complication for which the version was

‘formed as by the operation itself.

The rest of the Report is good but does not need any special comment.

THE MEDICAL AND CLINICAL REPORT OF THE EDINBURGH
ROYAL MATERNITY AND SIMPSON MEMORIAL HOSPITAL
FOR THE YEAR 1932

THE Report deals in detail with the 2,362 in-patients treated during the year,
and, in addition, brief notes are given on the work of the district and on the
activities of the antenatal and post-natal departments.

The in-patients are divided into the usual groups, ‘‘Booked’’ and ‘‘Non-
hooked,’’ and a footnote defines these terms as follows: ‘‘By ‘booked cases’
s meant that at least two visits to the antenatal out-patient department
were made by the patient. The term ‘non-booked cases’ includes all cases
not supervized antenatally by the hospital staff or at, City Antenatal
Centres, as well as true emergencies sent in by doctors.’’ It is well to have
such a definition, as in all probability different Registrars adopt different
standards.

The first section of the Report gives an account of the maternal mortality,
‘fd from it we learn that the total rate for the in-patients was only 1.1
oer cent, and that none of the booked cases died of sepsis. Then follow
summarized case-histories of all the fatal cases. On the whole these are
very good, but in some the reason for selecting the particular line of treat-
ment is not made clear. For example, Case No. 336 was admitted as a
‘failed forceps case’’ and was found to have a ‘‘compound presentation,
vertex L.O.P. and foot, and pulseless prolapsed cord.’’ She was delivered
by “‘internal version with extraction of the aftercoming head, following
perforation, by forceps.’’ There must have been some reason for not per-
forming craniotomy on the forecoming head, but it is not given. It is
somewhat surprising to read that in employing the alkaline treatment of
eclampsia it is apparently the custom in Edinburgh to use potassium citrate
intravenously: many years before the modern alkaline technique was
introduced Jardine strongly advocated the use of sodium instead of
potassium, which he held had a dangerously depressing effect.

Puerperal morbidity is next considered, but the value of this analysis is
impaired by the failure to adopt the Ministry of Health Standard. Another
unsatisfactory section is that dealing with stillbirth and infantile mortality;
the causes of death enumerated are very few, and indication is not given
whether or not any post-mortem examinations were made.

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JOURNAL OF OBSTETRICS AND GYNAECOLOGY

The subject of-abnormal labour is well treated. The tabulated data have
been carefully compiled and the short abstracts introducing each subsection
are most valuable. They deserve to be printed in much larger type and not
crushed into as little space as possible. On the other hand, it is not worth
calculating the percentages in some of the rarer complications. There were,
for instance, only seven cases of face presentation and only three cases of
brow presentation, yet we are told that the foetal mortality was 100 per cent
and 33.3 per cent respectively.

There is nothing of note in the section on the complications of pregnancy,
but it is interesting to observe the diversity of methods employed in the
treatment of eclampsia.

The Report ends with a statistical analysis of the obstetric operations,
which, although short, is good.

John Hewitt.

432

BOOK REVIEWS.

‘“Combined Textbook of Obstetrics and Gynaecology.”’ By J. M. Munro
Kerk, J. HAIR FERGUSON, JAMES YOUNG and JAMES HENDRY. Second
Edition. Edinburgh: E. & S. Livingstone.) Price 35/- net.

A great deal has been said and written in recent years about the essential

unity of obstetrics and gynaecology, yet it is still the exception to find both

subjects dealt with in a single textbook. We know of only three books in
which this has been done, the ‘‘ Combined Textbook ’’ now under review,

Fairbairn’s ‘‘Gynaecology with Obstetrics,’’ and the recently published

‘Obstetrics and Gynaecology’ by A. H. Curtis.

The ‘“‘Combined Textbook’’ is the pioneer of the series, and for that
reason alone deserves an honoured place on the shelves of our libraries.

It is difficult to understand why so few combined textbooks have made
their appearance, for it has always appeared to us to be the ideal method of
presenting the subjects of obstetrics and gynaecology. There are two pos-
sible explanations, either the majority of our authors do not feel capable of
dealing adequately with both subjects, or the subjects themselves are too
large to be compressed into a single volume of convenient size. There may
be something in the last-mentioned objection, for the first edition of the
“Combined Textbook’’ was described by its reviewer in this journal as a
solid tome of over 1,000 pages weighing about 41, lb., and the second
edition has 1,100 pages and weighs 5!; lb.

Like its predecessor, the new edition is strongly bound, well printed on
good paper, and copiously illustrated. The majority of the illustrations,
however, are in the form of line-drawings and, although they admirably
achieve their purpose, appear to us to be somewhat cold and cheerless.

The subject-matter has been brought thoroughly up to date and three
special chapters have been introduced dealing with the ‘‘Problem of Maternal
Mortality,’’ ‘‘The Infant in its First Month,’’ and ‘‘Radiology,’’ the two last
being contributed by specialists in paediatrics and radiology respectively.

Those acquainted with the views and practice of certain of the authors will
naturally turn to the pages dealing with dysmenorrhoea, functional uterine
haemorrhage, late toxaemias of pregnancy, and lower segment Caesarean
section, and they will find that these subjects are presented with judicial
impartiality and personal views not unduly stressed. The obstetrical section
is excellent, and coatains a full account of all the newer methods of diagnosis
and treatment.

In the gynaecological section there is a connecting chapter between
obstetrics and gynaecology which rightly lays stress on the amount of gynaeco-
logical pathology produced by injuries or infections acquired during labour
or the puerperium. This chapter also contains a description of the part
played by the endocrine glands in co-ordinating the reproductive processes
which might very well have been put into the earlier section of the book
dealing with the functions of the ovary and associated ductless glands.

With the exception of three chapters dealing with disorders of function,
displacements and infections (general considerations) the various gynaeco-

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JOURNAL OF OBSTETRICS AND GYNAECOLOGY

logical lesions are arranged anatomically, and in the case of endometrioma
this has resulted in a somewhat patchy treatment of the subject. It would
have been simpler and more satisfactory to devote a separate chapter to
endometriosis and endometrioma and include in it not only the various
ectopic endometriomata but also diffuse endometrioma (adenomyoma) of the
uterus. As the section dealing with gynaecological operations runs to 80
pages, we think it ‘might have contained a better description and better
illustrations of the Manchester operation for genital prolapse.

All these are minor criticisms of a book which deserves to become in-
creasingly popular with both teachers and students. No doubt a third
edition will soon be called for, and when that time comes we hope that it
will be possible by judicious pruning of both subject-matter and illustrations
to produce a lighter and cheaper volume more suitable to the needs of the
average student.

Daniel Dougal.

“X-ray and Radium Injuries: Prevention and Treatment,’’ by Hector A.
CoLwELL, M.B., Ph.D., M.R.C.P., D.P.H., and Sipney Russ, C.B.E.,
D.Sc., F.Inst.P. 14/- (Oxford University Press).

WE believe this book to be unique, inasmuch as it deals only with the
prevention and treatment of X-ray and radium injuries. It is true that in
works dealing with radiotherapy and diagnosis reference is made to the
subjects which Dr. Colwell and Professor Russ discuss, and also innumerable
papers have been written thereon, as witness the number of references
(989) which the authors have consulted. Nevertheless, it has remained for
the authors, with their wide experience, to present this most important
subject in such a complete and readable form.

How important the subject is can be gathered from the case records
reported of injuries and catastrophies which have resulted from the lethal
effects of X-rays and radium to those workers who were ignorant of the
precautions which are absolutely necessary for the protection of all following
this department of medicine. That it took a long time for radiologists to
realize that such injuries were due to the rays and not to other agencies
is well shown in the “‘history’’ of X-ray dermatitis when, before it was
settled that these rays were the fons et origo malorum, 10 other causes
were advanced as being responsible. Sir Humphrey Rolleston points out
in his ‘‘Foreword”’ that it was not till 1921, following the death in that year
of the distinguished radiologist, Dr. Ironside Bruce, from aplastic anaemia
after 20 years’ work, and the deaths of at least 100 pioneers from X-ray
carcinoma, that the first effort was made to standardize the means of
protection against the serious damage to which patients and radiological
workers are otherwise exposed. Again, “‘as has so often happened in the
history of medical science,’’ England made the original advance, ‘‘and the
action and recommendations of the British X-ray and Radium Protection
Committee have been followed in almost all civilized countries.’”’ The
establishment of this Committee was largely due to the initiative of the late
Dr. Stanley Melville, whose lamented death occurred after this book was
published. In this establishment he was very ably assisted by Professor
Russ as joint honorary secretary, who worked with Dr. Melville throughout.

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In this book the imperative need ‘‘for adequate and, indeed, fool-proof
protection’ to radiologists and their patients is described with a complete-
ness which leaves nothing to be desired. The book is divided into 14
chapters, and an Appendix containing the Recommendations of the Pro-
tection Committee and Methods of Dosage.

The first chapter deals with General Considerations, and this is followed
by chapters on the Skin, Respiratory Tract; Circulatory System; Alimentary
Tract; Generative System; Urinary Tract; Bone-Cartilage-Muscle-Connective
tissue; Adrenals-Thyroid-Thymus-Mammary Gland; Radiation ‘Sickness;
Changes produced by the prolonged action of Gamma radiation; Poisoning
by Radio-active substances and X-ray and Radium Quackery. When deal-
ing with the different sites of the body the authors discuss the subject under
two headings, X-rays and Radium, giving the immediate and remote effects
of undue exposure in each case, with the clinical, macroscopical and micro-
scopical findings and the best treatment at present available, and at the
end of each subject is given a list of references in relation thereto.

The chapter on the Generative System is the most complete in the
book. An account is given of the known results of irradiating cells in
general, in vivo, and of experiments in pregnant and non-pregnant animals.
The development of the germ-cells is described, the action of X-rays on the
ovary (including stimulation and sterilization, temporary and otherwise) is
fully discussed as well as irradiation in pregnancy.

In dealing with these subjects the authors have given as full a résumé as
they were able of the most authoritative opinions. The evidence is in many
cases conflicting, as is bound to be the case when statistical conclusions are
based upon a relatively small number of observations. So far as can be
seen, the authors hold to the opinion that though pre-conception irradiation
does not appear to be fraught with special dangers to subsequent offspring,
irradiation after pregnancy has developed is a proceeding which is attended
by the gravest risks. Most writers seem to be agreed in condemning post-
conception irradiation; the present reviewer has, however, had experience
of such a case where the mother was treated for carcinoma of the cervix
uteri 20 years ago when seven months pregnant. The child was not only
born normal, but in adolescence and young womanhood was a first-class
sportswoman. It appears to us to be of the first importance that as many
life-histories as possible of the offspring of irradiated mothers should be
collected and published, so that reliable statistical data may be obtained.
In the book under review a consideration of the evidence available to them
leads the authors to the conclusion that ‘“‘It may be said at once that
post-conceptional irradiation of the female pelvis is attended by the gravest
risks and is universally condemned. Should it be carried out unwittingly,
if the abortion does not occur spontaneously, the pregnancy should be
terminated before a viable foetus has time to develop.’’ Again, when
dealing with temporary sterilization, ‘‘A careful survey of the literature leads
us to the conclusion that the great bulk of responsible opinion is decidedly
against the temporary sterilization of women who may afterwards bear
children. As a contraceptive it is without question absolutely condemned.”’

It is pointed out that until we know more about the after-history of
such children in adolescence and maternity, the whole question must be
regarded as sub-judice, and, moreover, as one in which every practitioner

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can help by carefully recording all such cases as may come under his notice.
Above all, the progress of mental development calls for the most careful
attention.

This book contains a mine of valuable information, and the authors
pertinently remark that while such dangers and precautions to which they
have drawn attention may be more or less known to expert radiologists,
the increased use of higher voltage with X-rays and radium-beam therapy
may involve dangers which are as yet unknown.

We venture to suggest, to those whom it may concern, that this work
should be recommended as the textbook first to be read by those who
propose to practise in this department of medicine in order that they may
be well acquainted with its contents, since only this way does safety lie for
their patients and themselves. :

The value of this book is enhanced by the great experience which the
authors have had in the subjects with which it deals. Professor Russ has
been the physicist at the Middlesex Hospital since 1913, scientific secretary
of the Radiological Committee of the Medical Research Council and of the
National Radium Commission since their start, during which period he has
devoted a large amount of time and energy to the scientific technique of
radiological treatment and methods of protection. Dr. Colwell worked for
many years on pathological research at the Middlesex Hospital and for the
last 15 years has been engaged on radiological work, his many communica-
tions to the Medical Press disclosing an extensive knowledge of the subject.
There is an Index of Names of the authors quoted, 392 in number, and a
good Subject Index. The authors are to be congratulated on a fine piece of
work and for filling an unmistakable hiatus in radiological literature, and
members of the medical profession, especially those more intimately con-
cerned as radiologists, and indeed their patients did they but know, will
surely be greatly indebted to them.

Comyns Berkeley.

“Radiotherapy in the Diseases of Women,”’ by Matco-m DonaLpson, M.B.,
F.R.C.S. (London, Hodder & Stoughton). 131 pp., 16 illustrations.
Price 7/6.

Dr. DonaLpson has managed very succesfully to compress a large amount of

information, dealing with the treatment of certain of the diseases of women

by radium, into a surprisingly small compass. The present position of
radiotherapy is described lucidly and in simple language. |The book is
divided into three sections: (1) General, including some introductory remarks
on radium and X-rays; the biological action of radium and its method of
application and dosage. (2) Cancer, including a discussion on the cancer
problem and aetiology, pathology, diagnosis and treatment of cancer of the
uterus, vagina and vulva. (3) Benign conditions, including the treatment of
uterine haemorrhage and the dangers of radiotherapy. The various tech-
niques used in the treatment of cancer of the uterus are plainly described,
and the results obtained at clinics in France, Germany, Sweden, America
and England are tabulated. :

Dr. Donaldson is a well known,advocate for the periodical examinations

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of patients, and is of opinion that if any advance is to be made in securing
the early diagnosis oi cancer, three things are essential. First, better
education of the medical student in the diagnosis of cancer in its early stages
and periodical examination of the apparently fit by qualified practitioners.
Secondly, the establishment of a diagnostic centre in every town. Thirdly,
education of the public.

Although the author makes it quite clear that he is an enthusiastic
protagonist for the treatment of cancer of the uterus by radium and X-rays,
the statistics which he quotes pointing to results as good as those which
have been obtained by surgery, nevertheless he discusses the relative methods
of treatment of both methods very fairly. Altogether this is a very useful
book both for the qualified medical man and for the medical student.

Comyns Berkeley.

‘“An Outline of Practical Obstetrics for Nurses,’ by R. S. S. SratTHaM,

O.B.E., M.D., F.C.0.G. J. Wright and Sons, Ltd., Bristol. Price 2/6.
THis book is based upon the lectures given by Professor Statham to Pupil-
Midwives at the Bristol Royal Infirmary, and covers the syllabus of the
Central Midwives’ Board. The book is designed for the purpose of revision
for the examination of that Board.

The author advocates rectal rather than vaginal examination in the prac-
tice of midwives after examination, and we take it, therefore, that his
nurses are trained in rectal examination and not vaginal. The prophylactic
methods against puerperal sepsis carried out at the Royal Infirmary are
carefully described, special stress being laid on the thorough washing of the
vulva with soap and water before the child is born and the injection of
mercurochome directly after delivery.

The management of labour and the puerperium are described on sound
common sense lines, and the great importance of estimating the foetal! heart-
rate at regular intervals during labour is emphasized, since slowing indicates
interference. No mention, however, is made of the quickening which
precedes the slowing.

The toxaemias, antepartum haemorrhage and occipito-posterior position
are dealt with at length, and other abnormal presentations in considerable
detail. The foetal death-rate for breech delivery is given as 10 per cent, but
this figure most certainly under-estimates the danger of this presentation in
ordinary practice; moreover, if the reports of Maternity Hospitals in Great
Britain are referred to on this point it will be seen that the death-rate
therein is far higher. The author suggests that if the pelvis is large a living
and viable child, presenting by the shoulder, can be born by spontaneous
evolution, but he surely does not mean to advise that this manoeuvre should
be waited for, although no treatment is suggested for transverse lie before
labour.

In the discussion on puerperal sepsis the author suggests that if tem-
peratures are honestly taken sepsis will be found in 2.3 per cent of booked
cases and in 6 to 10 per cent of emergency cases. At the Royal Infirmary,
Bristol, morbidity is reckoned in any case which shows a temperature of
100.4°F. on two successive occasions 24 hours apart, thus differing from the

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B.M.A. standard of 100°F. twice any time between birth and the end of the
eighth day of the puerperium, and also the Ministry of Health standard of
100.4°F., or more, during a period of 24 hours, or has recurred during that
eriod.

: In the chapters on artificial feeding the author considers that Grade ‘‘A’’
T.-T. milk is suitable for a baby without sterilization, and that a healthy
child of eight weeks can take undiluted cows’ milk fully citrated. One and a
half ounces seems very little for each feed for the child between the seventh
and twenty-first day.

The concluding chapters deal with venereal disease and operative mid-
wifery. The book will undoubtedly be of great value for the purpose for
which it was written. M. W. Sparkes.

‘Clinical Contraception,’’ by GLapys Cox, M.B., B.S. William Heinemann,

London. Price 7/6.

Tuts book was written at the suggestion of the National Birth Control
Association, and the author feels it wise to state that she has no commercial
interest in any of the proprietary contraceptives mentioned. The book is
complete for the purposes for which it is written, including as it does in its
twelve chapters and appendix, the physiology of reproduction in relation to
contraception, methods of contraception such as chemicals, occlusive
pessaries, tampons, sponges, douches, the sheath, intra-uterine methods,
contraception for the normal and abnormal woman, an evaluation of contra-
ceptive methods and contraception and the Public Health Service.

The appendix contains the memoranda of the Ministry of Health on
Birth Control and the action taken by 64 local authorities under Memorandum
153/M.C.W., a list of birth-control clinics in London and the provinces,
and the hours of attendance, a very full list of contraceptives and the
addresses of the manufacturers from which they may be obtained, and a
bibliography and index.

Lord Horder, who provides an introduction, points out that the author’s
experience is large and her qualification for the task undoubted, and he feels
sure that this book will supply the information which many practitioners
have needed. Lord Horder points out that a large amount of the literature
on the subject of birth control deals with the controversial aspects of the
matter, very little of it being essentially practical. A book, therefore, ‘‘which
waives argument and at once gets down to the practice of contraception,
which is, in other words, as its title describes, ‘ clinical’ in its purpose, and

in, or parts of it, its matter is welcome.’’ From a perusal of its contents
this book will surcly be as interesting to the laity as to the medical profession.
AC.

“ Diagnostic Methods Used During the Later Months of Pregnancy and
During Labour,”’ by J. C. Winpeyer, M.D., Ch.M. (Sydney), F.R.A.C.S.,
F.C.0.G., etc. Published by Australasian Medical Publishing Co., Ltd.,
Sydney. Price 1/6.

Tue contents of this pamphlet, as the title suggests, consist of a description

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of the examinations performed upon pregnant women from the purely
obstetric point of view. It does not include the history or the ordinary
medical methods of examination used in antenatal supervision. The exact
procedure to be followed on making an abdominal examination, and the
information to be elicited by such examinations, is very fully described,
also methods of palpation, illustrated with photographs and diagrams,
showing how to estimate the degree of flexion and relative size of head and
pelvis. In discussing the technique of vaginal examinations and the infor-
mation to be gained, the author points out the difficulties in making an
accurate diagnosis by this method and considers that 75 per cent of labours
could be conducted considerably to the advantage of the patient if rectal
examination was substituted in normal labour.

The pamphlet concludes with a résumé of the examinations performed at
the University of Sydney upon women at the end of their pregnancies. The
teaching is sound and shows great attention to clinical detail. 5

M. W. Sparkes.

“Handbook of Midwifery for C.M.B. Students.’’ By W. O. GREENWooD,
M.D. John Bale, Sons and Danielson, Ltd. 97 pages, 23 illustrations.
Price 5/-.

THE author states that ‘‘from a very extended experience’’ of aspiring and
qualified midwives, he has found that ‘‘it is not so much the excellence of
the textbooks which helps the student, as that the alarming size of them
repels.’’ Further, the author points out that the reason the qualified midwife
has such a very hazy notion on some important bit of information is that her
textbook dealt with it so fully she purposely avoids it, its very length
making it ‘‘indigestible.”’

To remedy this unfortunate state of affairs the author has written this
Handbook, the size of which is not repellent and which he hopes contains
“all that the midwife actually needs to know.’’ What a hope!—at least so
far as the C.M.B. examination is concerned. The author quite correctly
states that “‘it is not necessary for the midwife to know exactly how to
apply the forceps or how to use the cephalotribe’’ (we have never met any
author of a book for midwives who thought it was, but our experience must
be limited in view of the above pronouncement)’’ but that it is necessary
to know what emergency treatment to apply in a bad case of haemorrhage.’’
We, therefore, turned to the description of the treatment advocated
for post-partum haemorrhage. Having given certain causes of post-
partum haemorrhage, including that of pulling on the cord to deliver the
placenta, the author continues: ‘‘In such cases always have plenty of cold
sterilized water and hot sterilized. If the placenta is retained it must be
removed. Pass the gloved hand to the very top of it and with the finger-
pulps (not the nails) peel it off gently in a downwards and sidewards direc-
tion. With the hand still in the uterus, massage on the internal one with
the other on the abdomen. Then withdraw the internal hand into the vagina
and again massage between the two. Now give a hot intra-uterine douche
and ergot. If the whole placenta is born don’t put the hand into the
uterus but give an intra-uterine douche,’’ etc. Nothing more, nothing less.

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It is obvious that this description is not so full that it will be the cause
of indigestion to the reader, nevertheless we fear that with the excitement
of the examination and the inevitable ‘‘plough’’ which would. result from
such an answer, the C.M.B. candidate may very well have a bad attack of
indigestion. We seem to remember that some textbooks of alarming size
have so far overstepped the mark as to mention Crede’s method, bimanual
compression, and the signs of separation of the placenta. The fault of this
book is entirely that of the omission of a large number of the fundamentals
of midwifery, probably so as not to make the book repellent in size, but we
do think it would be kind to warn the C.M.B. student of this fact in the
preface. H.C.

“The 1933 Year Book of Obstetrics and Gynaecology.’’ Obstetrics edited by
J. B. be Lee, Professor of Obstetrics, University of Chicago; Gynae-
cology edited by J. P. GREENHILL, Associate Professor of Gynaecology,
Loyola University Medical School. To be obtained from H. K. Lewis,
London. Price 11/6; 604 pp.

Tuis volume is one of the ten Practical Medicine Year Books which now
are in their thirty-third year. It contains a very complete survey of the
principal work which has been done in obstetrics and gynaecology during
1933, as will be realized from the fact that 786 papers by 680 authors have
been dealt with. The book is made additionally interesting by the remarks
of the editors at the end of many of the summaries and extracts. For anyone
who wishes to keep in touch with the work which has been done during the
past year, or whose duty it is to, this is the best book we know. It is

beautifully printed, and the illustrations are very well reproduced.

Comyns Berkeley.

’

‘“ The Midwife’s Dictionary and Encyclopaedia.’
Published by Faber & Faber. Price 3/6.

Revised by G. B. CaRTER. .

Tuts little book, which is of convenient size for the pocket or bag, covers a
wide area. Pupil-midwives will find the information given under the head-
ings Breech, Drugs, and Puerperal Sepsis especially helpful. The whole
book has been thoroughly revised and the contents brought up to date.

M. W. Sparkes.

‘“An Introduction to the Study of the Nervous System.’’ By E. E. Hewer,
D.Sc. (Lond.), and G. M. Sanpes, F.R.C.S. (Eng.), M.B., B.S. (Lond.).
Second edition. Heinemann. Price 21/-.

‘‘An Introduction to the Study of the Nervous System’’ should provide a
long-felt want to students, candidates for the Primary F.R.C.S., and as a
book of reference for surgeons and neurologists. It is divided into two
parts. The first part deals with the tracts in the spinal cord, connexions of
the cerebellum and corpus striatum, the blood-vessels of the brain, and
the autonomic nervous system. The second part is devoted to a description

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of the most recent views on the physiology of the nervous system and the
clinical interpretation of lesions at various levels. For example, after a clear
description of the normal physiology of the sensory paths, an account is
given of the signs produced by a lesion at various levels; the visual and
motor pathways, and so on, are similarly dealt with.

An outstanding feature of the book is the large number of the schematic
diagrams in colour; many of these are original in conception, and the
majority clear in purpose, and they have enabled the authors to reduce the
letterpress to approximately 130 pages.

Another excellent feature of this book is a description of the autonomic
nervous system which, in detail and accuracy, surpasses any account at
present to be found in any book of anatomy published in this country. The
widening interest that is being taken by surgeons in this important part of
the nervous system should make this section of the book specially valuable
for reference purposes. In the next edition Foerster’s work on ‘‘Cerebral
Localization’’ might be referred to, and a full description of nystagmus
might be given.

This book deals successfully with a difficult subject, and the authors are
to be congratulated on its production, and on the balanced opinion which
they have taken on controversial points.

Douglas McAlpine.

“The Relief of Pain in Childbirth,’’ by F. Reynotps, F.R.C.S.
(Edin.), M.C.0.G. (Medical Publications Ltd., London, W.C.2). 113 pp.
Price 10/6.

DuRING the last vear especially, the relief of pain in childbirth has been

the subject of many papers in the medical Press, of discussions in medical

societies and at public meetings, and is responsible for the foundation of
the Birthday Society which advocates the use of anaesthetics during
labour and the employment of chloroform capsules by midwives. So
far as we know, however, this is the first book to be published which deals
solely with the subject and which details the various methods of abolishing
pain during labour. The first chapter contains a short introduction, chiefly
of an historical nature. This is followed by a chapter on antenatal treatment,
upon which the author lays great stress, more particularly on its mental
and psychical side. The succeeding chapters deal with the different require-
ments during the two stages of labour, the properties required in the drugs
and methods to be used, those suitable and available for the first and second
stages of labour, and the position of the midwife with respect to anaesthetics.

With regard to the methods available to the midwife for the relief of
pain, the author realizes how important they are, more particularly as the
majority of women in labour are attended by midwives. This matter is fully
discussed, and the author arrives at the same conclusion as so many
eminent authorities have done, namely that at present there is not any
drug which will certainly relieve pain in the second stage of labour and
which is entirely safe in the hands of midwives. The author points out
that for the first stage of labour there are many drugs which a midwife is
allowed by law to use, such as the bromides, chloral hydrate, aspirin, and

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especially he favours paraldehyde. For the second stage of labour, how-
ever, the only useful drugs available are nearly all prohibited by law so
far as their use by midwives is concerned, consisting as they do of opium,
its derivatives, and the barbiturates.

It is true that chloroform is obtainable in any quantity by a midwife,
and of all the drugs used for the relief of pain in labour it is the best.
Apart from any other disadvantage there is the fact that if an unqualified
person administers chloroform and the patient dies he, or she, is liable to
a charge of manslaughter. Is it possible, then, so to arrange the administra-
tion of chloroform that there is not the slightest danger? The author,
after a careful consideration of several methods, arrives at the conclusion
that it is not, but is hopeful that one day this may be so by means of a
special apparatus which will automatically deliver only a certain percentage
and certain amount of chloroform vapour an hour, which apparatus shall
be sealed so that it is impossible for the chloroform to be replenished except
by some official other than the midwife.

Probably the method nearer safety than any other is that of chloroform
capsules, which were first used in the Great War and later suggested for
midwifery cases by Miss Pye, and the use of which has been advocated so
strongly by Carnac Rivett.

As the author points out, there is nothing, except the cost, to prevent
a midwife using a dangerous number of these capsules or using a large
number in quick succession, and apart from such maluse he states that not
less than 12 capsules, on an average, will be required for each case, which
means the use of four drachms of chloroform by the midwife without
immediate supervision. It is useless to maintain that an intelligent midwife
would be quite safe in using the capsules when it is obvious that an
unintelligent, careless or reckless one would be a source of distinct danger
if she had full power to administer these capsules without any legal
responsibility. The author quotes the case of a patient who received 66
capsules during 14 hours, and another who died of chloroform poisoning,
having received one and a half ounces of chloroform during five and a half
hours. In a report by Carnac Rivett dealing with the use of chloroform
capsules, more than 22 per cent of 342 patients received chloroform for three
hours, and of these nearly 30 per cent had been under the influence of
chloroform capsules for over nine hours. Whether one thinks it dangerous
or not for a qualified man to give chloroform for such a long period to a
woman in labour, there can be no two opinions about the matter when
midwives are concerned.

This book is eminently readable and the author is to be congratulated
on the production of such a useful book.

Comyns Berkeley.

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Review of Current Literature.

Tais Review will contain the lists of contents and abstracts of the more
important articles fron» the following journals with which the ‘Journal
of Obstetrics and Gynecology of the British Empire’’ exchanges :—

British.—The Lancet ; British Medical Journal; The Cancer Review :

Canadian.—The Canadian Medical Association Journal ; Bulletin Médical
de Quebec.

Australian.—Medical Journal of Australia.

Indian.—The Calcutta Medical Journal.

American.—American Journal of Obstetrics and Gynecology; The
Journal of the American Medical Association; Surgery, Gynecology
and Obstetrics.

French.—La Gynécologie; Gynécologie et Obstétrique; Bulletin de Ia
Société d’Obstétrique et de Gynécologie de Paris.

Belgian.—Bruxelles-Médical.

Italian.—Annali di Obstetrica e Ginecologia; Archivo di Obstetrica e
Ginecologia.

German.—Archiv fiir Gynakologie; Zeitschrift fiir Geburtshilfe und
Gyniakologie; Zentralblatt fiir Gynakologie; Monatsschrift fiir Geb-
urtshiilfe und Gynakologie; Miinchener Medizinsche Wochenschrift.

Scandinavian.—Acta Obstetrica Scandinavica.

South American.—Boletin de la Sociedad Obstetricia y Ginecologia
de Buenos Ayres.

Japanese.—-Japanese Journal of Obstetrics and Gynecology.

The Review of Current Literature will keep the readers of this Journal
in touch with current literature throughout the world. At the end of each
year an Index of all the subjects contained in the articles of the above
journals is printed. Arrangements will also be made to include abstracts of
important articles on border-line subjects, such as Physiology, Biology and
Biochemistry.

LIST OF ABSTRACTORS.

London: J. BeatTTIE, F.R.C.S.; A. C. BELL, F.R.C.S.; R. K. Bowes,
F.R.C.S.; J. Cameron, F.R.C.S.; R. L. Dopps, F.R.C.S.;
R. C. LicHtwoop, M.D.; D. H. MacLeop, F.R.C.S.; J. A. Moore,
M.B.; C. D. Reap, F.R.C.S. (Edin.); F. Rogues, F.R.C.S.; R.
WINTERTON, M.D.

Huddersfield: W. E. CRowtTuer, M.B.

Leeds : R. H. B. ApAmsSon, M.D.

Liverpool: M. Datnow, M.D.; P. Matpas, F.R.C.S.

Sheffield: W. W. KinG, F.R.C.S.

Glasgow: JANE H. FILSHILL.

Liverpool: M. DatNow, M.D.; P. Matpas, F.R.C.S.

Glasgow: JANE H. FILSHILL; R. SHARMAN, M.D.; H. MacLennan, M.D.

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British Medical Journal

January 6th, 1934.

“Ovulation and menstruation. Wilfred Shaw.
February 3rd, 1934.

Torsion of the normal Fallopian tube. Alistair McEachern.

Treatment of an uncommon obstetric difficulty. T. P. Mulcahy.
February 24th, 1934.

‘Sub-acute inversion of the uterus. R. L. E. Downev.

March 3rd, 1934.
*Construction of a vagina from a loop of sigmoid colon. E. Rock Carling.

OVULATION AND MENSTRUATION.

The author assigns the date of ovulation as the fourteenth day of the
menstrual cycle. He arrives at the date from a study of the ovaries in 36
cases, removed at operation, and examining the stage of the follicle. He
confirms his results by a study of the cyclical changes occurring in the
endometrium. It has been shown that the secretory phase of the endometrium
develops after the fourteenth day of the menstrual cycle.

CONSTRUCTION OF A VAGINA FROM A Loop oF SIGMOID CoLon.

The mesentery of the small intestine was, in this case, too short to allow
a double loop to be drawn down to the perinaeum. The author describes how,
as an alternative, a loop of the sigmoid colon, seven inches in length, was
isolated and its anatomically proximal end drawn down to the perinaeum.
The divided parts of the bowel were united end to end. The patient made
a satisfactory recovery. Upon a review of all the circumstances the author
expresses the opinion that it is probably wiser to use the colon than small
intestine in these cases.

SUBACUTE INVERSION OF THE UTERUS.

The author was called to see a patient on the third day after delivery,
on account of continued loss of blood. The placenta had been manually
removed. The uterus was inverted and the bladder was very distended,
The patient’s condition was poor. Reduction of the inverted uterus per
vaginam failed and laparotomy was performed. The contraction ring was
incised posteriorly and at the same time pressure was exerted on the uterus
per vaginam. The patient recovered.

D. H. MacLeod.

The Lancet

January 6th, 1934.
Pathological results of Caesarean section. Douglas Lindsay.
February 24th, 1934.
‘Treatment of puerperal infection due to streptococcus pyogenes by organic
arsenical compounds. L. Colebrook and R. Hare.

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REVIEW OF CURRENT LITERATURE

TREATMENT OF PUERPERAL INFECTION DUE TO STREPTOCOCCUS PYOGENES BY

ORGANIC ARSENICAL COMPOUNDS.

Sixty-six cases of puerperal infection with streptococcus pyogenes were
treated with arsenical compounds. They are divided into three groups.
The first group comprised those cases in which the infection was limited to
the tissues of the genital tract. The spread of infection beyond these t.ssues
appeared to occur less frequently than in the controls, but the results were
not convincing. The arsenic content of the lochia was low and streptococci
did not disappear from it. The second group comprised those cases in which
the blood-culture was positive, but generalized peritonitis was not present.
The recovery-rate in this group was even slightly below that of the controls.
The cause of failure appeared, at autopsy, to be due to the presence of septic
clots in the large pelvic and abdominal veins. In the third group, in which
generalized peritonitis was present with positive blood-cultures, there was no
apparent effect of treatment by arsenical derivatives.

D. H. MacLeod.

The Canadian Medical Journal Association.

Vol. xxx, No. 1, January, 1934.
*Weight-taking in pre-natal care. V. J. Harding and H. B. Van Wyck.
*The standing position as an aid in replacing the retroverted uterus. I. O
Foucar.
*Tendencies in human fertility. W.L. Hutton.
Vol. xxx, No. 2, February 1934.
*Choline as related to labour. F. Walker and D. N. Henderson.
*The relief of pain in labour with nembutal. F.G. McGuinness.

WEIGHT-TAKING IN PRE-NATAL CARE.

Weight-taking is an important means of detecting an incipient toxaemia
of later pregnancy. Gains up to five pounds a month duriag p:egnancy are
to be considered normal. Toxaemia rarely develops in this g-oup. Gains
of more than eight pounds should arouse suspicion of toxaemia. A diet
deficient in salt, with a restricted caloric intake is indicated. The closest
supervision should be exercised. Albuminuria, oedema and hyperpiesis are
preceded by gains in weight. The prevention and control of retention 01 water
may avert a toxic process.

An increase of the mother’s weight due to obesity is to be treated by a
restricted diet. This will in no way affect the child, whch develops normally,
even if the mother is markedly undernourished. Cases of toxaemia are seen
in which the foetus shows massive oedema, and it is probable that milder
cases of this occur in the absence of obvious oedema. ‘ The sudden post-natal
loss of weight frequently seen in large babies is often due to loss of excessive
water. Special dieting in the pre-natal stage by reducing this foetal oedema
may facilitate labour. The pre-natal routine was to allow a normal diet and a
normal intake of fluid during the first three-months. The same was allowed
during the second trimester, except that a moderate restriction in salt was
advised, provided the patient did not gain more than five pounds a month.
When the gain was more than this amount, a salt-free diet was prescribed

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and the caloric intake was definitely reduced. At the same time the patient
was seen fortnightly, weekly or even more frequently, the urine being exam-
ined and the blood-pressure estimated. On this restricted diet a slowing in
the rate of gain was observed and, in some cases, a certain heaviness in the
appearance of the face would disappear, as well as various subjective symp-
toms, such as sluggishness and dullness.

Observations were made on 726 unselected cases. Of these 62 had monthly
gains of eight pounds, or more. All the cases of toxaemia occurred in this
group, except one which was known to be a case of chronic nephritis. In all
but one a marked increase of weight preceded either albuminuria, or a rise
in blood-pressure.

The use of scales should be general in every maternal and pre-natal clinic.
Eight cases are cited to illustrate the importance of weight-taking, and refer-
ences to the literature are given.

THE STANDING PosITION as AN AID IN REPLACING THE RETROVERTED UTERUS.

The author deprecates the view that a host of symptoms, pelvic and
general, are attributable to retroversion of the uterus. There is, however, a
group of patients in whom displacement causes symptoms and correction
brings relief. The principles of replacement are: (1) pushing the cervix back-
ward and upward, and (2) bringing the fundus downward and forward.
The second factor frequently requires the use of vulsella applied to the cervix
to pull the uterus downward, so that the fundus can be dislodged from the
hollow of the sacrum. In the standing position gravity and the intra-abdo-
minal pressure are operative in pushing the uterus downward. This is further
aided, when necessary, by the patient’s stooping forward and bearing down.
It is easy under these conditions to tilt the fundus forward and then push it
upward and forward into its normal position. Of course the method is not
applicable when the uterus is bound down by inflammatory adhesions. Re-
placement is occasionally effectual and permanent even without the use of a
pessary. Usually, however, after correcting the retroversion, a pessary is
required. This can then be inserted with the patient in the prone position.
This position is not recommended for routine examination, although even here
it is sometimes of value. It was used in the days of Smellie (1697 to 1763)
for examining pregnant women.

TENDENCIES IN HUMAN FERTILITY.

The population of the world doubled itself in the nineteenth century, and
is now estimated at 1,900,000,000. Malthus then uttered the warning that
the production of food must ultimately lag behind the needs of a continuously
expanding population; for a few decades it seemed as if this might come true
and that Western civilization might soon encounter the problem of over-
population which now confronts Japan, China and India; but forces were
already at work to prevent suchacatastrophe. The latter half of the nineteenth
century demonstrated beyond the shadow of a doubt that the birth-rate in all
countries under the influence of Western civilization was entering upon a
period of consistent decline. In the Scandinavian countries the birth-rate
has decreased since the year 1855, in France since 1865, in England and Wales
since 1880. Between 1850 and 1854 the birth-rate in England and Wales

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averaged 33.84 per 1,000; between 1925 and 1927 it had fallen to 17.56.
During the same period the birth-rate fell in France from 27.50 to 19.35; in
Holland from 36.16 to 24.35; in Italy from 38.81 to 28.49; in Germany from
38.2 to 18.6; in Belgium trom 30.0 to 18.3. In Canada, excluding Quebec,
from 26.4 to 20.9, during the decade 1921 to 1930. When the manner of
this decease in the birth-rate is estimated, we discover factors of supreme
and immediate importance. In the United States it was found that the wives
were childless in the following percentages; professional men 18, business men
16, skilled workers 15, non-skilled workers 14, farm owners 10, farm labourers
7. Surveys and investigations have conclusively proved that the wives of
professional men have fewer children than those of skiiled artisans, who again
have fewer children than common labourers, and labourers have fewer
children than the blind, deaf and feeble-minded.

Investigations in Canada among business and professional men show an
average family of 2.42 children, a strong indication of dwindling population.
Investigation among families at universities gave an average of 3.5 and 3.41
children. It was found that families whose children attend municipal schools
had an average of 3.7 living children. Of the families sending a pupil to the
School for the Deaf, there was an average of 3.47 living children and of fami-
lies who provided patients for the Mental Health Clinics—not predominantly
feeble-minded, rather a ‘‘social problem group’’—the average was 4.44 living
children. Families sending a child to the School for the Blind had an aveage
of 5.1 living children. Families contributing a patient to the Ontario Hos-
pital for the Feeble Minded had an average of 8.7 living children. From these
figures the falling birth-rate is definitely shown to be greatest among those
who have reached the highest social level and to have fallen least among
physical and mental defectives. The evidence is convincing that the group
from which the feeble-minded springs is reproducing itself much faster than
the general population. It is probably the only one in which the birth-rate
has not fallen.

The causes of the falling differential birth-rate are considered. It is not
due to birth control, for it began years before the world became acquainted
with the phrase; nor is it due to the emancipation of women; becatise, as has
been shown, the number of wives under 45 years of age has not declined.
Both in England and Germany the acquisition of a title has resulted in the
most pronounced falling off in the birth-rate.

Two important factors are steadily at work reducing the number of
children per family. One is the modern urge for social and economic advance-
ment; those who struggle most successfully have neither the opportunity nor
the intention of raising a large family; and, secondly, to the general exodus
from rural to urban life. In the days when the majority of the population
were peasants a large family was not only an economic possibility, but an
asset. The industrial revolution changed that. There has been an ever in-
creasing stream from the countryside to the city. The chief motive is
undoubtedly a desire for improving the economic outlook, and in the cities
there is greater opportunity for advancement and a vast proportion of men
have dedicated their lives to personal gain, thus creating an atmosphere fatal
to the procreation of children. All this took place during the latter half of
the nineteenth century. It is most important that means be sought to

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oppose this pernicious influence and to encourage people of sound stock to
reproduce their kind. Furthermore, it is strongly urged that State control
of the multiplication of the unfit, especially sterilization of the feeble-minded
should be instituted, for should the present conditions be allowed to continue,
in a few generations it will not be the meek but the feeble-minded who will
inherit the earth. A long list of references to statistics is appended.

CHOLINE AS RELATED TO LABOUR.

Choline is found in nearly all living cells. The commonest source is the
adrenal cortex, where the quantity is nine times as great as in the medulla.
It is a parasympathetic stimulant, causing increased salivation, bronchial
spasm, intestinal peristalsis and a fall in blood-pressure. It antagonizes
adrenalin, inhibiting its action on bronchial spasm, on the rate of the heart
and on the blood-pressure. One milligramme of choline counteracts the
pressor effect of a quarter of a milligramme of adrenalin. As the amount of
adrenalin in the blood rises, the quantity of choline also rises to neutralize
its effect. The administration of atropin brings about the disappearance of
choline from the blood. Blood from the suprarenal vein was shown to
contain one milligramme of choline per cubic centimetre of blood. After
the administration of pilocarpine this rose to 1.9 milligrammes per cubic
centimetre. Choline chloride is the common form in which it is found.
Several derivatives, more powerful in their physiological effect, have been
cited and a series of compounds with increasing toxicity has been isolated.
It seems that if the blood-pressure should rise very high, which cannot be
checked by the available choline chloride, then one of these more powerful
and toxic derivatives may be formed to meet the sudden demand.

Investigations have been made in which the choline content of the blood
of the umbilical cord was estimated and the results correlated with the
duration of labour and with the maternal blood-pressure in both multiparae
and primiparae. It was found that the average choline content of the
umbilical blood is higher in cases in which labour is of less than 10 hours’
duration than in those in which it is longer than 10 hours. The explanation
given is that the greater concentration of choline stimulates the uterus to
stronger contractions and thus reduces the duration of labour. It was
found that the duration of labour increased directly with the systolic blood-
pressure up to 130 millimetres of mercury in primiparae and up to 120 in
multiparae.

The choline content of the umbilical cord increased directly with
increased blood-pressure up to 130 millimetres. The relation between the
blood-pressure and the duration of labour is explained in part by the theory
that the blood-pressure is due to the increasing quantity of adrenalin present
in the maternal blood. This adrenalin seems to have a depressor action on
the uterine muscle, weakening contractions and prolonging labour. When
the blood-pressure is more than 130 labour is frequently shortened, and the
explanation given is that choline chloride is probably not available in
sufficient quantities to neutralize the effects of the adrenalin present, and
more powerful choline derivatives are formed, especially the amino-choline
substances with their toxic properties and effect on skeletal muscles, tending
_ to produce convulsions.

Choline chloride seems to have two functions in labour; first, neutraliza-
tion of adrenalin, and secondly, stimulation of the uterus,

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THE RELIEF oF PAIN In LaBoUR WITH NEMBUTAL.

Only within comparatively recent years has a serious attempt been made
to relieve the pains of labour. Opium and its derivatives were first used,
later chloral hydrate. Ether and chloroform have been employed extensively
since their introduction. Nitrous oxide and ethylene serve a useful purpose,
but are expensive and require a skilled anaesthetist for their administration.
Morphine and scopolamine were introduced in 1902 by Steinbuchel. Later,
in 1906, the idea of producing amnesia and not analgesia was put forward.
Gwathmey advocated synergic anaesthesia; in this, morphine is employed
with a solution of magnesium sulphate in the strength of 50 per cent and a
rectal injection of oil, ether, quinine and novocain. Until recently the
author made use of repeated doses of scopolamine with one small initial dose
of morphine, usually a sixth of a grain, with gas or a combination of chloro-
form and ether in the late stage. Fresh enthusiasm has attended the
introduction of the shortly acting barbiturates, amytal, pernocton and
nembutal. These are highly hypnotic with low analgesic efficiency.

The author presents a report on 140 full-time confinements. Nembutal
was used orally in doses of three grains repeated every two hours; a sixth
of a grain of morphine was added to the initial dose. This had a marked
effect on the respiration of the mother and child, especially the latter. The
largest dose administered was 15 grains in 24 hours. The method was later
changed to the following: a patient weighing 160 pounds is given six grains
as an initial dose, a second dose of three grains, and a grain and a half
every succeeding two, or more, hours is given till delivery if the amnesia is
not complete. Treatment is started in primiparae when the os is half
dilated and in multiparae when it admits two fingers. The effects on the
mother were to produce complete amnesia in 52 per cent of the cases and
partial amnesia with very short intervals of consciousness in 4o per cent;
in 12 per cent of the cases the patients became restless and eight per cent
must be regarded as failures. In half the cases little or no additional
anaesthesia was required; in a quarter of the cases a few drops of chloroform
and ether were given to deliver the head. There was not any interference
with the course of labour, no increased loss of blood, the third stage was
normal, and convalescence was greatly improved. There was not any
apparent increased risk to the foetus.

Contra-indications are respiratory obstruction, respiratory infections,
asthma, low blood-pressure and serious damage to the cardio-vascular
sys'em and kidneys.

J. Lyle Cameron.

Bulletin de la Société Medicale de Quebec.

No. 1, January 1934.
*Hematocolpos: imperforate hymen. J. Caouette and O, Garant.

HEMATOCOLPOS : IMPERFORATE HyMEN.

A young girl of 18 sought treatment because she had never menstruated.
Every month from the age of 13 she had complained of pain in the lower
abdomen with slight abdominal distension. These pains lasted from 24 to 48

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hours. On three or four occasions, when the pains were severe, she uncon-
sciously voided her urine during the night. Otherwise she was well. For five
years, before seeking medical aid, the mother had carried out treatment at
home; her treatment included such measures as the administration of hot gin,
mustard plasters to the upper part of the thighs, and the administration cf
every drug that came to her knowledge. On admission to hospital her normal
healthy appearance, with amenorrhoea and abdominal swelling, suggested
pregnancy. She was well developed, with wide hips, hair on the pubes and
axillae; there was no secondary pigmentation or mammary activity; the pelvis,
the pulse-rate, and the temperature were normal. On abdominal examination
a hard, regular, immovable tumour filled the pelvis and reached to the level
of the umbilicus. There was no contraction felt on palpation and no foetal
sounds on auscultation. On making a vaginal examination, there was a soft
sacculation about the size of a fist bulging from the vaginal orifice. Puncture
of this showed that it contained blood. A diagnosis of imperforate hymen
with retention of the menses was made. The membrane was split with a
bistoury and two litres of homogeneous liquid of the colour and consistence of
chocolate-cream were evacuated. Examination then revealed a greatly dis-
tended vaginal cavity, with a depth of 16 centimetres, and a breadth of five
centimetres. The uterine cervix was very large and soft. The external os
was widely open but the internal os was tightly contracted, only admitting
a filiform bougie. The uterine body was freely mobile, normal in size and
consistence, with a cavity measuring five centimetres. The ovaries were
easily felt owing to the distention of the vagina. They were normal. A hot
vaginal douche was given, and an application of iodine was made. The
patient made a swift and uneventful recovery, leaving for home a few days
after the operation. A good prognosis was given for future periods and the
possibility of pregnancy.
J. Lyle Cameron.

The Medical Journal of Australia.

: Vol. ii, No. 23, 1933.
*The early diagnosis of cancer of the cervix uteri. C. Coghlan.

Vol. ii, No. 24, 1933.
A case of polyneuritic psychosis during pregnancy. A. Prior.

Vol. a1, INo;, 25, 1693.
Tubal block and other adnexal lesions from the aspect of sterility. S. C.
Fitzpatrick.

Vol. ii, No. 26, 1933.
*Eclampsia. A. J. Gibson.

i, No. 2, 1934:
*The antenatal treatment of the toxaemias of pregnancy. J. B. Dawson.

THE EaRLy DIAGNOSIS OF CANCER OF THE CERVIX UTERI.
The author begins by- lamenting the number of cases of carcinoma
of the cervix seen when the time for operative removal is past. Schiller

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found that at first carcinoma is a localized disease with few signs of its
presence and an absence of subjective symptoms. He found that in early
cases there is a superficial carcinomatous layer of growth, about the thick-
ness of epithelium, spreading over the surface of the cervix. At first there
is neither ulceration nor evidence of downgrowth of the epithelium. Down-
growth may not appear until months later. Schaffer has pointed out that
the epithelium covering the surface of the cervix contains glycogen. It is
not soluble in water. Carcinomatous cells do not contain glycogen.

When stained with Lugol’s iodine, cells containing glycogen stain a
mahogany-brown, while the carcinomatous cells remain white. This forms
a very simple test for an early carcinoma. White, unstained spots are seen
under the following conditions: (1) early carcinoma; (2) hyperkeratosis,
from prolapse and exposure; (3) healed luetic infection; (4) trauma from the
examination. This method of diagnosis does not apply to an ulcerated
growth. Suspicious areas should be examined microscopically.

ECLAMPSIA.,

The author collected 101 cases of eclampsia at the Women’s Hospital,
Crown Street, Sydney, and analysed the cases along lines similar to those
used at the British Congress of Obstetrics and Gynaecology in 1922. The
following conclusions were reached:

1. A symptom suggestive that eclampsia may occur is a blood-pressure
which is low in the early months of pregnancy, gradually rises in the later
months of pregnancy to 140 millimetres of mercury, or more, and is
associated with oedema and albuminuria.

2. Eclampsia is more prevalent in the winter months in Sydney, and at
that time the mortality is higher.

3. Eclampsia is more prevalent in persons below the age of 21 years in
Sydney; but it may occur at any age. The mortality is low before the age
of 21 years and is higher over the age of 30 years.

4. The prognosis is worse in eclampsia supervening before the thirty-
sixth week than later in pregnancy. The severe type predominates before
the thirty-sixth week, and the mild predominates after the thirty-sixth week.

5. The classification adopted by the London Committee into mild and
severe types is an advance in the study of the disease, and its general
adoption would make future reports more valuable.

6. The incidence of eclampsia in Sydney is slightly lower than that of
Great Britain, but the incidence in primigravidae and multiparae, and the
percentages of mild and severe cases, are about the same.

7. The most important prognostic phenomena are, in order of import-
ance, the degree of coma, the number of fits, the temperature, the amount
of albuminuria, the pulse-rate, and the height of the blood-pressure.

8. Ante-partum eclampsia is associated, in Sydney, with a higher mor-
tality than post-partum eclampsia.

g. The severe type of eclampsia is about twice as dangerous in multiparae
as in primigravidae.

10. Eclampsia can be prevented in most cases by thorough antenatai
supervision, but it cannot be so prevented in all cases.

11. The history of previous illnesses is of value in determining the
liability to eclampsia.

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12. Eclampsia recurs in about three per cent of cases and is followed by
signs suggestive of permanent renal damage in about 20 per cent of cases.

13. Conservative treatment with a minimum of obstetric interference
yields the best result.

14. The results of a modified form of Stroganoff’s treatment, with gastric
and colonic lavage, at the Women’s Hospital compare very favourably with
the average results in Great Britain and America, but fall below Stroganoff’s
latest results.

15. Eclampsia does not show any marked variation in its general mani-
festations in Sydney as compared with other parts of the world.

ANTENATAL TREATMENT OF THE TOXAEMIAS OF PREGNANCY.

Vomiting of pregnancy is usually classified into (1) vomiting due to
associated conditions, such as gastric ulcer, cerebral tumour and tabes
dorsalis; (2) reflex vomiting, due to retroversion and cervical erosion; (3)
neurotic vomiting, which may not exist without a toxaemic basis; (4).
frankly toxaemic vomiting.

The changes brought about by the imposition of an embryo on the
mother result, in most cases, in the vomiting of pregnancy. Most women
adjust their metabolism to the changes and the vomiting passes off. The
remainder pass into the state of toxaemic vomiting of pregnancy.

First there is the woman who suffers from the usual vomiting of preg-
nancy which tails to pass off but becomes increasingly severe. She becomes
dehydrated. The density of the blood becomes increased and the blood-
proteins break down, with the result that poisonous protein-products are
added to the initial toxins of pregnancy. Once this has occurred successful
treatment is not easy. In the earlier stages biochemical investigations are
not of much assistance, the findings being those of starvation. Signs of
renal damage are not usual. The temperature and the pulse-rate are normal.

Large amounts of fluids must ,be given with five per cent of glucose.
Treatment in hospital is essential. A copious enema should be given and
solid food witheld for 24 hours. A sedative drug should be given at night.

The intake and output of fluid must be recorded and the urine examined.
Solid carbohydrates can be added to the diet after 24 hours and the amount
rapidly increased. Proteins, fats and chlorides should be restricted.

If vomiting prevents the taking of fluid by mouth, it should be given
rectally or, in severe cases, intravenously. The intake of fluid should be
double its output. Basins for vomiting should be kept out of sight. The
patient should remain in hospital until she is taking ordinary meals and
walking about. Favourable signs are cessation of the sickness, an improve-
ment in the appearance, with loss of anxiety, moist tongue, increased
diuresis, the disappearance of ketone from urine, natural sleep, and an
improvement in mental composure. A few cases will not respond to this
treatment. Serious indications for emptying the uterus are (a) persistence
of vomiting; (b) severe loss of weight; (c) persistence of low urinary output;
(d) the output of fluid exceeding its intake; (e) persistence of acetone and
aceto-acetic acid in the urine; (f) albuminuria with casts; (g) the pulse-rate
persistently more than 100; (h) the temperature persistently more than
100°F.; (i) inevitable spontaneous abortion.

There remain the graver cases which result from prolonged dehydration

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or arise ab initio. These patients can seldom be saved except by evacuation
of the uterus, which must be done promptly.

The toxaemias of late pregnancy. Recent work has shown that only 40
per cent of women suffering from toxaemia of pregnancy recover completely.
The kidneys are permanently damaged in 50 per cent of the cases; 10 per cent
suffer from permanent chronic nephritis. The severity of the damage to the
kidneys is dependent on the duration of the albuminuria. Five per cent of
primigravidae suffer from albuminuria. The source of the toxins is not
definitely known. The liver and kidneys, being the detoxicating and
excretory organs, suffer most.

1. Mild toxaemic conditions associated with pregnancy. Albuminuria only
occurs during the last two months of pregnancy. It is often associated with
slight oedema of the ankles and a blood-pressure which remains at 150/90.
There may be headache. The prognosis to mother and child is excellent.

The patient should be treated by rest in bed, free purgation and restric-
tion of the diet. Saline aperients are the most satisfactory aperients. At
first only fruit, milk, and gelatine are allowed, but other foodstuffs may
soon be increased. If improvement does not take place labour should
be induced.

z. Pre-eclamptic toxaemia. The albumin is greater in amount and the
blood-pressure is higher, ranging from 150/100 to 200/130. The oedema is
more marked. Pre-convulsive symptoms appear if the patient progresses
unfavourably.

3. Eclampsia. This is the result of failure of treatment or fulminant
toxaemia. It is associated with massive albuminuria, a blood-pressure as
high as 250 millimetres of mercury, scanty urine, jaundice, blood in the
urine, grave ocular symptoms, marked oedema, and mental disturbances. It
may occur suddenly, but there is usually some warning, such as increased
blood-pressure or albuminuria. Among other conservative treatment recom-
mended is the giving of alkalis and calcium by the mouth, or intravenously,
the use of calcium and glucose in the form of calcium gluconate and the
exhibition of various endocrine preparations.

W. R. Winterton.

Bulletin of the Johns Hopkins Hospital.
Vol. liv, No. 1, January 1934.

*Prolongation of pregnancy and the complications of parturition in the
rabbit following the induction of ovulation near term. F. F. Snyder.

PROLONGATION OF PREGNANCY AND THE COMPLICATIONS OF PARTURITION IN
THE RaBBIT FOLLOWING THE INDUCTION OF OVULATION NEAR TERM.
The role of the corpora lutea in parturition was studied by the induction

of ovulation near term by injecting an extract from the urine of pregnant

women to produce a new set of corpora lutea at the maximal stage of
activity.

The following observations were made. (1) In most animals the
pregnancy was 32 to 40 days more than normal. (2) Post-mature foettis
developed to enormous sizes. (3) Pituitrin administered at term failed to

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induce parturition, despite dosage a thousand times greater than the normal
effective dose. (4) The functional reserve of the placenta was maintained,
since glycogen was present after a gestation of 41 days.

The following conclusions were arrived at. (1) There was not any support
for the view that the onset of parturition was due to changes in the foettis,
senility of the placenta or mechanical distension of the uterus. (2) The
retention of the foetfis in utero is under hormonic control and parturition
coincides with the termination of the life of the corpus luteum.

J. H. Moore

The Journal of The American Medical Association.

Vol. cii, No. 2, January 13th, 1934.
The effect of pregnancy on the urinary tract. H. P. Lee and W. F.
Mengert.

Vol. cii, No. 3, January 2oth, 1934.
Ovarian therapy. The relation of the female sex hormone to haemophilia.
J. Brem and J. S. Leopold.

Vol. cii, No. 4, January 27th, 1934.
*Foetal risks in the first stage of labour from complications of the umbilical
cord demonstrated by ‘‘amniography.’’ J. P. Gardiner.
The aetiology and treatment of anaemia in pregnancy. M. B. Strauss.

Vol. cii, No. 5, February 3rd, 1934.
*Bronchial asthma as a complication of pregnancy. 8B. Green.
Proctological defects in twins. C. C. Mechling.

Vol. cii, No. 6; February 1oth, 1934.

*Two important biological factors in fertility and sterility. (a) Is there a
safe period? (b) Menstruation without ovulation as a possible cause of
sterility. E. Novak.

Menstruation and safe period. (Editorial.)

Vol. cii, No. 7, February 17th, 1934.
“Syphilis and pregnancy: an analysis of the outcome of pregnancy in
relation to treatment on 943 cases. J. L. McKelvey and T. B. Turner.

Vol. cii, No. 8, February 24th, 1934.
The clinical significance of Roentgenometry in obstetrics. H. Thoms.

Vol. cii, No. 9, March 3rd, 1934. |
Abruptio placentae following acute placental infarction. R. A. Bartholomew.

FoETAL RISKs IN THE FIRST STAGE OF LABOUR FROM COMPLICATIONS OF THE
UMBILICAL CORD DEMONSTRATED BY ‘‘AMNIOGRAPHY.”’
Complications of the umbilical cord too frequently cause foetal asphyxia
during the first stage of labour, for which blame cannot be attributed to the

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conduct of labour. The symptoms of these complications are delay in the
progress of the labour, disturbance in the foetal heart-rate, and persistent
malpresentation of the child when other causes of such malpresentation have
been excluded. The author claims that, by the intra-amniotic injection of
strontium iodide, or skiodan, followed by an examination of the uterus by
the X-rays, not only can the placenta be outlined but also the umbilical
cord and sometimes the sex of the foetus may be determined.

BRONCHIAL ASTHMA AS A COMPLICATION OF PREGNANCY.

In a patient with true bronchial asthma of anaphylactic origin, the
attacks are markedly exacerbated by pregnancy and the outlook may
become alarming. In the type of bronchial asthma, which is directly
related to the sexual cycle, the attacks may appear with each menstrual
period, be absent during pregnancy and lactation, and then recur with the
reappearance of the menses. On the other hand, the attacks may occur
only during pregnancy, or even during pregnancy with a foetus of one sex
and not with one of the other.

The attacks are occasionally associated with a mild toxaemia and are
relieved when the toxaemia subsides under the usual conservative treatment.
Normally the treatment consists of combating the asthma and disregarding
the pregnancy. Termination of the pregnancy, at the best, only assures a
return to the pre-gestational state. If attacks occur, not accompanied by
toxaemia, and due specifically to the pregnancy, therapeutic abortion might
be warranted in severe cases. Attacks of bronchial asthma are a decided
menace to the life of the foetus.

The author gives the details of two cases of asthma associated with
pregnancy, one of pre-existing asthma with the attacks aggravated during
the pregnancy, and the second in which the asthmatic attacks were first
noticed during pregnancy but continued after pregnancy. The first patient
died shortly after an asthmatic attack when the foetus was not yet viable.

Two IMPORTANT BIOLOGICAL FACTORS IN FERTILITY AND STERILITY. (a) Is
THERE A SAFE PERIOD? (b) MENSTRUATION WITHOUT OVULATION AS A
PossIBLE CAUSE OF STERILITY.

Most often ovulation occurs about the twelfth to the fourteenth day of
the normal cycle of 28 days. The life of the ovum after extrusion from the
follicle is probably not more than a day or so, according to some only a few
hours. There is not any proof that coitus produces ovulation in the female,
and if this does not occur then fertilization can take place only within a few
days of ovulation. It is now assumed by the author that spermatazoa lose
their capacity for fertilization in two or three days.

Based upon the above assumptions, it is reasonable to suppose that the
time at which fertilization can occur is about three days after the phase of
ovulation, to allow for the possibility of the survival of previously injected
spermatazoa, and another day to allow for the possibility of the survival of
the ovum for that period after ovulation.

In cases of sterility the author suggests that in a small group the failure
to conceive may be due to a failure to ovulate and that the cyclical bleeding
is due to menstruation in the absence of ovulation. It is also suggested
that if such cases occur then it should be possible to make a diagnosis by the
examination of curettings obtained from the uterus during the normal pre-

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menstrual phase of the cycle, and if no secretory phase is demonstrable in
the curettings, it may be assumed that the patient has not ovulated and,
therefore, has no corpus luteum in the ovaries.

SYPHILIS AND PREGNANCY.

Nine hundred and forty-three pregnancies occurring in syphilitic women
were analysed with regard to the presence, or absence, of congenital syphilis
in the offspring; particular attention being paid to the effect of maternal
antisyphilitic treatment on the outcome of pregnancy. The relative value,
in the diagnosis of congenital syphilis, of such signs as the Wassermann test
on the blood in the umbilical cord, placental histology, and X-ray examina-
tion of the infants’ bones for syphilitic epiphysitis were considered. Among
the cases in which Wassermann’s reaction on the umbilical blood was
negative the infant was not syphilitic in 86.2 per cent, and among those in
which it was positive the infant was normal in only 18.6 per cent.

Among cases in which the placenta was normal on macroscopic and
microscopic examination the infant was proved not to be syphilitic in 79.9-
per cent, while among cases showing syphilitic changes in the placenta the
offspring was syphilitic in all but 12.1 per cent. When these two diagnostic
aids were considered together the information obtained was more valuable
than when each was considered alone. Infants presenting evidence of
syphilitic epiphysitis invariably exhibited other evidence of congenital
syphilis. Among children who did not show any abnormalities on X-ray
examination, 20.5 per cent were subsequently shown to have congenital
syphilis.

The beneficial effect of antenatal arsphenamine therapy is shown by the
fact that among pregnancies occurring in untreated syphilitic mothers the
infant was born alive in only 54.1 per cent, and 64.5 per cent of living
offspring were syphilitic, while the adininistration of as little as one gramme,
or less, of arsphenamine changed these figures to 89 per cent and 27 per cent
respectively. Administration of larger amounts of arsphenamine or related
products brought about a further reduction in the foetal mortality and in
the percentage of syphilitic offspring; when four grammes (from 12 to 14
injections) were given none of the offspring were syphilitic.

The administration of heavy metals, mercury or bismuth, in addition to
arsphenamine, enhanced the good results achieved with the last named alone.
Better results were obtained when the maternal treatment was started in the
first half of pregnancy than when begun in the latter half. It was found
particularly important that the arsenical preparation should be given during
the two months preceding delivery. The results in cases treated before
pregnancy and not during pregnancy were, on the whole, quite as good as
when the mother was treated only during pregnancy. Antisyphilitic treat-
ment, both before and during pregnancy, yielded results superior to
treatment during either period alone.

John Beattie.

American Journal of Obstetrics and Gynaecology.

Vol. xxvi, No. 5, November 1933.
~ *Granulosa-cell tumours of the ovary. M. Schulze.
*The problem of irregular menstruation. C. F. Fluhmann.

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*An analysis of 575 cases of eclamptic and pre-eclamptic toxaemias treated by
intravenous injections of magnesium sulphate. E. M. Lazard.
“Haemorrhage following Caesarean section. J. M. Slemons.
Nicotine in breast milk. W. B. Thompson.
*The treatment of prolapsus uteri, with special reference to the Manchester
operation of colporrhaphy. W. Fletcher Shaw.
Prevention of cancer of the cervix uteri. H. S. Crossen.
*The occipito-posterior position. G. C. Melhado.
End-results in treatment of pelvic infection. A. H. Aldridge.
Breech delivery, with reference to X-ray measurement of the foetus and
maternal pelvis. T. R. Goethals.
*The alleviation of pain in obstetrics. J. H. Moore.
*Report of two cases of granulosa-cell tumours of the ovary. E. F. Daily.
An internal outlet pelvimeter. S. Hanson.
Self-retaining vaginal speculum. G. S. Beardsley.
Society transactions.
Department of Reviews and Abstracts.
Collective Review.

No. 6, December 1933.
*Evaluation of radiation therapy in malignant disease of the female generative
tract. W. P. Healy.
*A clinical and experimental study of endometriosis. E. Allen.
The calcium problem in pregnancy. C. B. Reed.
Five hundred women with serious heart diseases followed through pregnancy
and delivery. F. B, Carr and B. E. Hamilton.
Trauma and compensation in gynaecology and obstetrics. J. R. Miller.
Congenital aspiration pneumonia in stillborn and newborn infants. F. C.
Helwig.
Changes in the urinary tract during pregnancy. I. J. Strumpf.
Fertility in the male. D. L. Belding.
The treatment of post-partum retrodisplacement of the uterus. W. M.
Findley.
Amniography with skiodan injections. F. L. Adair and M. E. Davis.
Chlorothymol as an antiseptic in obstetrics. A.C. Beck.
Spontaneous rupture of uterus after myomectomy. R. A. Hurd.
Early detection of chorion-epithelioma by means of the anterior pituitary
hormone tests, with report of a case. M. A. Castallo.
Two cases of calcification of the uterus associated with missed or incomplete
abortion. F. R. Smith.
Absence of urethra due to obstetric trauma.
The birth of a giant foetus. J. E. Hobbs and W. Scrivener.
Spontaneous rupture of uterus with a seven months’ pregnancy. A. A.
Schenone.
Carcinoma of both Fallopian tubes, both ovaries and the corpus of the
uterus. C. Culbertson.
Empirical use of blood injections in the newborn to lessen brain haemorr-
hage. W. L. Carr.
Tumour of the pelvis resembling embryonal-cell carcinoma of the ovary.
M. T. Goldstine.

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Parasitic dermoid of the ovary with spontaneous amputation of the
Fallopian tube. J. P. Greenhill.

Postnatal infection due to short-chain haemolytic streptococci. L. E
Frankenthall.

Society transactions.

Book reviews.

GRANULOSA-CELL TUMOURS OF THE OVARY.

Margaret Schulze has found five cases of granulosa-cell tumour, including
one further case since the original paper was written, amongst 44 ovarian
carcinomata which have occurred during the past 19 years in the University
of California. She reports seven cases, of which three were originally diagnosed
histologically as medullary carcinomata. She follows Meyer’s classificauon ot
cylindroid, folliculoid and sarcomatoid types and thinks that the pathological
diagnosis is not difficult if these characteristics are kept in mind.

The clinical diagnosis can be easily made before puberty by the presence
of sexual precocity, and after the menopause by signs of rejuvenation. It is
difficult to recognize the disease during active sexual life, but the presence of
large amounts of follicular hormone in the urine should be very suggestive.
Its absence after operation should be valuable in prognosis. The test was
apparently only used once, and that post-operatively, in this series. Schulze
stresses the frequency of haemorrhages and the hyperplasia of the endo-
metrium.

THE PROBLEM OF IRREGULAR MENSTRUATION.

Fluhman, from an analysis of 76 records of the menstrual cycle in normal
women, finds that there is irregularity in at least two-thirds of the women.
Abnormal rhythms do not require treatment unless there 1s a change for the
worse.

AN ANALYSIS OF 575 CASES OF ECLAMPTIC AND PRE-ECLAMPTIC TOXAEMIAS.

Lazard writes in support of the intravenous use of 20.0 c.c. of 10 per cent
magnesium sulphate in the treatment of pre-eclamptic toxaemia and eclamptic
convulsions. The pre-eclamptic cases have been given intravenous magnesium
sulphate if the blood-pressure is 150, or more. The eclamptics are given an
injection every hour until the convulsions cease.

Three hundred and seventy-one pre-eclamptics were treated by the mag-
nesium sulphate method, with a mortality of 1.6 per cent; and four per cent
of the treated cases developed convulsions. The gross mortality among the
eclamptic cases was 13.33 per cent. The author has observed no ill results
from the injections.

HAEMORRHAGE FOLLOWING CAESAREAN SECTION.

Morris Slemons records two cases (one fatal) of secondary post-partum
haemorrhage after Caesarean section. The second case was saved bya timely
hysterectomy. He comments upon the absence of reports of such accidents,
which he thinks must be due to ‘‘very human reasons.’’ He draws an analogy
between these haemorrhages and accidental haemorrhage.

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THE TREATMENT OF ProLapsus UTERI WITH SPECIAL REFERENCE TO THE

MANCHESTER OPERATION.

Fletcher Shaw, writing of the Donald-Fothergill vaginal plastic operation
for prolapsus uteri [though surely it should be prolapsus vaginae], sum-
marizes his experience of the operation as the one which is best for both old
and young. He has been successful in 95.35 per cent. There has been no
trouble in the patients who have had subsequent pregnancies. The liability
for the prolapse of the vagina to recur is stated to be less than <5.0 per cent.
Fixation of the uterus is only necessary in the very rare cases of almost
complete absence of the muscular tissue of the pelvic diaphragm.

Position.

This paper is an analysis of 976 cases of occipito-posterior position, with
special reference to the author’s method of dealing with delayed labour from
this cause. The technique advised is as follows: In cases of delay with the
os fully dilated the head is pushed up above the brim. In this position
forceps are applied to the sides of the head with the pelvic curve directed to
the same side as the occiput. The head is then made to enter the brim in
the transverse diameter and the occiput is rotated forward in the cavity.
Melhado has had great success with this method.

THE ALLEVIATION OF PAIN IN OBSTETRICS. -

Moore favours the use of barbiturates by oral, rectal or intramuscular injec-
tion, combined with pantopon and scopolamine for normal labours. He finds
that intravenous administration may cause an alarming drop in blood-pressure
and does not advise this method of administration except in eclampsia, when
doses of 0.5 to 1.0 gm. followed by hypertonic dextrose solution give definite,
prompt, and gratifying results.

REPORT OF Two CASES OF GRANULOSA-CELL TUMOURS OF THE OVARY.
Both the cases which Daily reports occurred in comparatively young
women. Both patients had prolonged amenorrhoea, and the ovarian tumours
were of the folliculoid type of granulosa-cell tumour.
The endometrium in the one case examined was not hyperplastic, but
there were some cystic glands.

EVALUATION OF RADIATION THERAPY IN MALIGNANT DISEASE OF THE FEMALE

GENERATIVE TRACT.

This review of the present position of radiation therapy for carcinoma
is not suitable for abstraction, but it is none the less valuable. A few points
may be noted. Radiation treatment of epithelioma of the vulva is unsatis-
factory. Healy now excises the vulva, but treats the vaginal glands by
radiation with deep X-rays. The cauliflower carcinomata of the vagina react
well to radium; the circumscribed lesions less well, and the sclerotic type very
badly. Healy advises radium at the time of diagnostic curettage, followed by
hysterectomy six or eight weeks later. He has not found that the operation
was made more difficult by the pre-operative radiation.

Post-operative radiation is recommended for all malignant ovarian tumours
and good results have been noted even in inoperable cases.

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In cancer of the cervix with ulceration the best results have followed deep
X-ray therapy and local antiseptics, followed by the application of radium to
the cervix.

A CLINICAL AND EXPERIMENTAL STUDY OF ENDOMETRIOSIS.

After a review of the symptoms of endometriosis Allen advances an aetio-
logical theory suggested by the frequency of irregular bleeding and the cystic
hyperplasia of the endometrium. He postulates an endocrine imbalance, and
cites some evidence in favour of it.

W. W. King.

La Gynécologie.

August 1933.
*The dangers of intra-uterine pessaries. R. Keller.
*Conservative surgery of the uterus and adnexa. H. Roulland.
September 1933.
*Causes of intra-uterine death of one of twins. A. Brindeau.
November 1933.
*Uterine haemorrhage occurring during secondary syphilis. C, Daniel.
*Tuberculosis of the cervix. B. Dupeux.
December 1933.
*Endometrioma of the uterine body. G. Cotte and A. Trillat.
*Comments on three cases of interstitial ectopic gestation. Dr. Roton.

Tue DaNGERs OF INTRA-UTERINE PESSARIES.

Keller in a long paper stresses the dangers of intra-uterine pessaries. He
admits that their use under strict supervision is not harmful for dilatation
of the cervix in cases of stenosis. A list of complications is given from
general peritonitis and septicaemia, to ectopic gestation, and is supported by
abstracts of several personal cases. In 78 cases of abortion associated with
such instruments, 80 per cent were septic. These were ascribed to the trauma
and to the action on the cervical plug of mucus.

CONSERVATIVE SURGERY OF THE UTERUS AND ADNEXA.

Roulland raises a series of questions on this subject, which are: (1) Should
the ovaries or an ovary be conserved when hysterectomy is performed? (2) At
what age is it desirable to conserve ovarian function? (3) In which cases is
conservation of one or both ovaries indicated? Theoretically he agrees that
ovarian function is desirable, but he points out that at least 50 per cent of
cases in which an ovary is left after hysterectomy have menopausal symptoms
afterwards. He supports this statement by cases in which cystic appearances
were found; for these he suggests X-ray therapy. He urges conservation in
women up to 40. He practises conservation in cases of' fibroids with normal
ovaries and in all cases of ectopic gestation. He distinguishes between
gonococcal infection, in which he advocates removal of the ovaries, and
streptococcal infection, in which he is in favour of their conservation.

He discusses operative technique emphasizing the importance of handling
the tissues as little as possible, and describes a method of ovarian grafting

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for certaia, cases. A plea is put forward for fundal hysterectomy in.view. of
the endocrine disturbance following complete hysterectomy. He divides the
presacral nerve ini cases in which he performs grafting.

CAUSES OF INTRA-UTERINE DEATH OF ONE OF TWINS.

The comparative infrequence of the condition is noted, and a full biblio-
graphy is given with clinical notes of 12 cases. It is more common in
uniovular than binovular pregnancies. The author points out that many
cases can be missed if routine placental examination is not carried out. Both
general and local causes are given; of the former syphilis and toxaemia of
pregnancy are stressed. In diagnosis radiography is the only sure method,
unless the changes in the skull characteristic of foetal death can be felt.

UTERINE HAEMORRHAGES OCCURRING DURING SECONDARY SYPHILIS.

Secondary syphilis usually manifests itself, if it affects menstruation, in
amenorrhoea or oligomenorrhoea, but may occasionally cause menorrhagia or
metrorrhagia. The two last named symptoms may easily be missed in
diagnosis unless the cutaneous phenomena are present, or can be very exces-
sive, and even endanger life. The pathology is summarized by vascular
changes in the uterus, anaemia, and ovarian changes. Usually those
occurring in the early stages are the more severe. Anti-syphilitic treatment
is the only one of value and curettage is condemned.

TUBERCULOSIS OF THE CERVIX.

Apparently 200 cases of this lesion have been published, which comprise
only three per cent of all cases of pelvic tuberculosis. The mode of infection
is threefold: (1) secondary genital spread from the Fallopian tubes via the
uterine mucosa; (2) the possibility of direct vaginal infection; and (3) rarely,
infection via the blood-stream. It is usually met with in young adult women,
and predisposing factors are multiparity, infection and trauma of the cervix.
The symptoms are equivocal and may be mistaken for carcinoma. The patho-
logical types are: (a) a form resembling carcinoma; (b) a more ulcerative
form having the appearance of an erosion; and (c) a rare miliary form. The
diagnosis can only be made by biopsy. The treatment depends on the extent
of the disease, generally and locally, in the genital tract. With widespread
infection general treatment aided by local cauterization is indicated. In

purely genital cases hysterectomy is best or amputation of the cervix in more
localized cases.

ENDOMETRIOMA OF THE UTERINE Bopy.

The authors publish an account of this condition and quote to of their
own cases. Pathologically, circumscribed and diffuse varieties are to be dis-
tinguished, both are frequently mistaken for fibroids until enucleation is at-
tempted or the tumour cut. Brief mention is made of the theories of causa-
tion and the clinical symptoms. In treatment conservatism is advocated on
account of the youth of the patients.

COMMENTS ON THREE CaSEs OF INTERSTITIAL Ectoric GESTATION.
Apparently ectopic pregnancy is common in Indo-China, and Dr. Roton
refers to 50 cases of his own, including three of the interstitial type. Two of
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these were treated by subtotal hysterectomy with one death, and one by
cuneiform resection. He stresses the gravity of the condition and the difficulty
in diagnosis prior to rupture. Theoretically it should be possible in the
presence of three signs: (1) an alteration in the uterine axis, (2) asymmetric
insertion of the Fallopian tubes, and (3) the altered relation of the round
ligament to the affected Fallopian tube. Operation is essential; hysterectomy
or local resection is employed.
R. K. Bowes.

Gynécologie et Obstétrique.

Vol. xxviii, No. 5, November 1933.
*A histological classification of carcinoma of the Fallopian tubes. Cornil,
Mosinger, Imbert and Harvey.
*Caesarean section during labour; a contribution to its operative technique.
Merger.
\ The transplacental transmission of gonorrhoea to the foetus. Slobozianu
and Herscovici.
The action of opaque and caustic media on the pelvic organs. Grigorieva,
Morosoff and Serdukoff.

Vol. xxviii, No. 6, December 1933.

*The external signs of ovulation in women. Séguy and Simonnet.

*Delayed Caesarean section; its indications and the management of the
trial of labour. Merger.

*Massive suture as a method of avoiding suppuration of the abdominal wall
after the lower segment Caesarean operation. Mahon.

A case of cervical fibro-chondroma: simple and malignant branchiogenic
tumours. Lantuéjoul and Seydel.

A HISTOLOGICAL CLASSIFICATION OF CARCINOMA OF THE FALLOPIAN TUBES.

The authors describe two cases of carcinoma of the Fallopian tubes; the
first was a typical papillary carcinoma; the second an intramural growth
composed of tubules and cysts lined by an epithelium of columnar, cubica!
and flat cells with a clear basophilic protoplasm. After a general review of
the histology of tubal carcinoma, they distinguish three types. (1) Carcino-
mata arising from true tubal epithelium. (2) Carcinomata arising in areas
of metaplasia, either endometrial or mucous. (3) Carcinomata developing in
Wolffian remains.

CAESAREAN SECTION DURING LABOUR; A CONTRIBUTION TO ITS OPERATIVI

TECHNIQUE.

Merger describes the various procedures which have been devised t
permit the safe performance of Caesarean section in the presence of infection
Two types of infection have to be anticipated: primary infection occurring
during the course of the operation, and secondary infection developing durin;
the puerperium.

Exteriorization of the uterus, before its incision, would seem effectiv:

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in preventing primary infection in the corporeal operation. The real diffi-
culty arises with regard to secondary infection; among the procedures which
have been adopted to prevent its occurrence are covering the scar with
omentum, various types of drainage, exteriorization of the scar by suture
of the uterus and its peritoneum to the parietes, either before or after the
incision into the uterus, and Portes’s operation of temporary exteriorization
of the uterus.

Merger considers the danger of primary infection is as great in the
corporeal operation as it is in the lower segment operation. The advantage
gained by a low incision of the peritoneum is offset by the inability to
exteriorize the uterus. The dangers of secondary infection are, on the other
hand, much less in the lower segment operation than in the corporeal
operation. The author discusses the established factors in this comparative
safety; the thinness of the wall of the lower uterine segment makes for good
coaptation, the mobility of the peritoneum over the lower uterine segment
enables the operator satisfactorily to cover the uterine incision with
peritoneum; the pelvic site of the incision, its remoteness from the intestine
and the immobility of the lower segment are additional factors.

The increased risks of the lower segment operation are infection of the
opened pelvic cellular tissue, the occurrence of phlebitis in the neighbouring
venous plexfis, and the still present, although minimized, risk of peritoneal
infection.

After describing the various modifications of the operation devised to
overcome these dangers, the author describes the operation as he performs
it. The following are the special features of his technique:

1. Care in displacing both recti muscles so as not to separate the fascia
transversalis from the peritoneum in the posterior wall of the rectus sheath.

2. A reversed V-shaped incision (nearly 90 degrees between the limbs)
through the fascia transversalis and the parietal peritoneum.

3. A corresponding reversed V-shaped incision in the peritoneum cover-
ing the lower segment, the purpose of the V-shaped incision being to
diminish the amount of separation of the recti demanded by a transverse
incision.

4. Retraction of the two triangular flaps downwards to their base and
suture together of the upper edges of the parietal and uterine peritoneal
incisions.

5. Leaving a Mikulicz drain behind in contact with the uterine incision
and leaving the initial parieto-uterine suture intact.

The author has performed the operation on nine infected cases with
satisfactory results.

THE EXTERNAL SIGNS OF OVULATION IN WOMEN.

The authors describe the various methods which may be used to
determine the time of ovulation in women. They claim that ovulation is
attended by the appearance of an abundant translucent, liquid secretion
from the cervix, which, they consider, renders the cervix temporarily
permeable to the spermatozoa. A transient increase in the sexual desire
may be noticed at this time. A few days later there is an undue
desquamation of the vaginal epithelium. Symptomatically ovulation may

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be marked by intermenstrual pain and, very occasionally, by slight inter-
menstrual bleeding.

Biological assay of folliculin in the urine gave conflicting results in four
cases out of 12 which the authors investigated, but in the remaining eigi:t
there was concordance between the maximal amount of hormone in the
blood and the appearance of the characteristic cervical secretion. These
findings were confirmed in four out of five cases in which laparotomy was
performed.

The authors have performed two successful artificial inseminations by
choosing a time in the menstrual cycle when the cervical secretion,
characteristic of ovulation, was noticed, on the twelfth and thirteenth days
after menstruation, respectively. In a third case in which artificial
insemination failed at this period, investigation of the urinary folliculin
reached its maximum on the twenty-second day of the cycle and artificial
insemination, performed on the twenty-first day, was successful.

DELAYED CAESAREAN SECTION; ITS INDICATIONS AND THE MANAGEMENT OF

THE TRIAL OF LABOUR.

Merger divides the factors which determine the management of a case
of a trial of labour into three groups: static, i.e. the size of the pelvis and
the foetus; dynamic, i.e. the strength of the uterine contractions; and
finally the estimation of the effects of the pains, viz. the relation of the
position of the head to the symphysis pubis, changes in the orientation of
the head, whether the lower uterine segment is thick or thin.

Out of 108 cases of late lower segment Caesarean section, three of which
were heavily infected, he has had three deaths, a mortality of 2.7 per cent.

MASSIVE SUTURE AS A METHOD OF AVOIDING SUPPURATION OF THE
ABDOMINAL WALL AFTER THE LOWER SEGMENT CAESAREAN OPERATION,
Since the publication by Brouha, in 1930, of figures which showed that

out of 5,685 lower segment operations suppuration occurred in the abdominal

wall in 414 cases, or 13.73 per cent, Mahon has adopted the plan of suturing
the abdominal wall in one layer with massive through-and-through sutures.

In 25 consecutive cases he has not had any parietal suppuration. He

stresses the importance of careful insertion of the sutures so that correspond-

ing layers are approximated.
P. Malpas.

Bulletin de la Société d’Obstétrique et de Gynécologie de
Paris, etc.

No. 9, November 1933.
SOCIETE D’'OBSTETRIQUE ET DE GYNECOLOGIE DE PARIS.
*Cervico-facial ecchymosis developing during labour. Cathala and Bernard-
Griffiths.
Myoma of the anterior wall of the vagina. Petridis.
The diagnosis of menopausal haemorrhage. Quenu and Beéclére.
*Menopausal bleeding of ovarian origin. Béclére.

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SOCIETE D’OBSTETRIQUE ET DE GYNECOLOGIE DE BORDEAUX.
Extrusion of the uterine suture through the vagina after a lower segment
Caesarean section. Andérodias and Péry.
» Severe puerperal infection; recovery after laparotomy and the use of
Vincent’s serum. Péry, Balard and Mangé.
Myomectomy at the third month of pregnancy with normal delivery at
term. Mahon.

KEUNION OBSTETRICALE ET GYNECOLOGIE DE MONTPELLIER.
An unusual complication of the induction of labour. Battle and Sauvy.
A malignant leiomyoma of the uterus. Mourgue-Molines and Guibert.
Aberrant mammary carcinomata. Massabuau, Giubal and Guibert.
Intestinal obstruction due to an ovarian cyst. Riche and Mourgue-Molines.
A fibroid of the broad ligament. Lapeyre and Estor.

Rupture of the uterus due to a neglected shoulder presentation. Lapeyre,
Battle and Sauvy.

Torsion of a healthy Fallopian tube after rupture of the bladder. Riche
and Guibal.

The medicinal induction of labour. Brémond.

Observations on a classical Caesarean section for placenta praevia. Delmas
and Battle.

Haematocoele due to rupture of a non-pregnant, chronically inflamed
Fallopian tube. Godlewski.

A case of apparent stenosis of the cervix. Delmas and Battle.

The biological diagnosis of pregnancy. Delmas, Roume and Godlewski.
Chorea gravidarum. Brémond.

REUNION OBSTETRICALE ET GYNECOLOGIQUE DE NANCY.

Rupture of the uterus and abdominal pregnancy. Hartemann and Lacour.

“Two cases of acute and fatal ulcerative endocarditis. Fruhinsholtz and
Michon.

Sarcoma of the breast. Hamant and Chalnot.

No. 10, December 1933.

SOCIETE D’OBSTETRIQUE ET DE GYNECOLOGIE DE PARIS.

The symptoms of retroversion of the uterus. Bernot.

Normal pregnancy following the removal of the right ovary and the left
Fallopian tube, for a cyst and an ectopic gestation respectively. Bernot.

Torsion of a right ovarian cyst with acute appendicitis. Stoian and
Costesco.

Measurement of the length of the foetus as a guide to the period of
gestation. Le Lorier.

Electrocution of the foetus iz Cathala.

A lower segment Caesarean operation for rupture of the scar of a previous
classical operation. Brault.

The Aschheim-Zondek test in a case of molar pregnancy. Chevrel-Bodin
and Brault.

“tysterography in the diagnosis of intra-uterine lesions. Béclére.

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REUNION OBSTETRICALE DE LILLE.
Personal observations on the diagnosis of early pregnancy by hormon:|
methods. Palliez and Gernez.
*Absence of both kidneys with multiple malformations in a foetus at the
twenty-fourth week of gestation. Gernez and Christiaens.

CERVICO-FACIAL ECCHYMOSIS DEVELOPING DURING LABouR.
Three cases of this condition developing spontaneously at the end cf
normal iabours are described; a cause could not be found in any of them.

MENOPAUSAL BLEEDING OF OVARIAN ORIGIN.

Béclére considers that true menopausal menorrhagia is characterized by
a triad of symptoms; a sudden onset of the haemorrhage, periods of
amenorrhoea, and the irregular alternation of amenorrhoea and menorrhagia.
He prefers to treat the condition with a castrating dose of the X-rays after
verification of the diagnosis by hysterography and curettage.

Two Cases oF ACUTE AND FataL INFECTIVE ENDOCARDITIS DURING

PREGNANCY.

The authors describe in detail two cases of infective endocarditis develop-
ing during pregnancy. One of the patients was known to have had a
valvular lesion before pregnancy began; the other patient had previously
been healthy. In both cases morning sickness was very severe. In the first
case, the presence of renal tenderness, pus and blood in the urine led to the
initial diagnosis of pyelonephritis. In the second case the association of
pyrexia and abnormal physical signs in the lungs led to the initial diagnosis
of early phthisis. The authors emphasize the insidious onset of the disease
and the difficulties of diagnosis encountered, pointing out that the condition
should be borne in mind when any atypical persistent infection is
encountered. One patient died undelivered; the other died 15 days after a
spontaneous abortion.

ABSENCE OF BOTH KIDNEYS WITH MULTIPLE MALFORMATIONS IN A FOETUS

AT THE TWENTY-FOURTH WEEK OF GESTATION.

A male foetus, with complete absence of both kidneys and ureters
associated with normal development of the genital organs, normal develop-
ment of the adrenals, absence of the left umbilical artery, an imperforate
anus, hemiplegia of the arm, and club foot, is described.

HYSTEROGRAPHY IN THE DIAGNOSIS OF INTRA-UTERINE LESIONS.

The radiological appearances of the uterus in the presence of various
intra-uterine lesions are reviewed in this paper. Béclére claims for the
method a very exact control of subsequent diagnostic curettage, which,
however, he always practises before hysterography.

His principal conclusion is that a normal uterine contour indicates 4
functional lesion; a deformed contour a surgical lesion.

P. Malpas.

Archiv fiir Gynikologie.
Band 1, Heft 1, 1934.
*Acute purulent endomyometritis causing spontaneous rupture of the uteru..

F. Gunther.
466

‘REVIEW OF CURRENT LITERATURE

The influence of atmospheric conditions on the incidence of eclampsia. H.
Eufinger and J. Welkersheimer.

Alterations in the tone of the foetal heart on entry into the contracted pelvis.
K. Dierks.

Researches concerning the activity of the foetal heart. Part III: The in-
fluence of cephalic pressure on the frequency of the foetal heart-beat.
W. Rech.

Experimental researches concerning the relations between pregnancy and the
thyroid gland: an answer to the criticism of K. J. Anselmino and F.
Hoffmann. J. Friedmann.

*The question of interruption of pregnancy in pulmonary tuberculosis, in the
light of the modern treatment of phthisis. W. R. Glaser.

The destruction of erythrocytes in the blood of the umbilical cord. H.
Schwalm.

Experimental studies concerning the physiology of the first respiratory
stimulus. H. H. Klemperer.

A note concerning the alteration of hepatic function during pregnancy.
M. Kojima.

The functional state of the liver and reticulo-endothelial system after
nephthropathy. F. G. Dietel and A. Polak.

The porphyrin content of human amniotic fluid. R. Fikentscher.

*The differentiation of hormonal substances by the Reid-Hunt, Aschheim-
Zondek and oestrous tests, especially in the fluid of ovarian cysts. H. O.
Kleine and H. Pahl.

Osteogenesis imperfecta, diagnosed in the uterus. G. Danelius.

*Insular function and fecundity. R. Liegner.

Antefixura uteri supplicata: the exact correspondence of this operation with
the pelvic hysteropexy of Pestalozza. (A reference to Kakuschkin’s
article in the previous volume). FE, Debiasi.

*The genesis of adenosis endometrioides in laparotomy scars. M. Kranzfeld.

Further remarks concerning the paraganglionic tissue in the ovaries. J.
Wallart.

Heft 2.

This issue begins with a congratulatory note from the Editors to Professor
G. A. Wagner, of the Charité Universitats-Frauenklinik in Berlin, on the
attainment of his sixtieth birthday.

Anthropological researches concerning the alterations of the form of the new-
born head during the first eight days of life. W. Neuert.

The behaviour of the melanophore-hormone in human blood during gesta-
tion. A. Jores and O. Helbron.

The volume of the heart during pregnancy. H. Bonhold.

The significance of morphological alterations of the thyroid gland during
pregnancy. L. Herold.

Statistical considerations concerning acute and chronic inflammation of the
vermiform appendix. L. Schack.

*Autochemical modification of the cervical secretion. W. Nuernbergk.

Researches. concerning the anterior pituitary hormone. K. Ehrhardt and
H. Ruhl.

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Heft 3.
*Primiparae in the fifth decennium. J. v. Khreninger-Guggenberger and E.
‘Leatenmayer.
The thyroid-hormone content of the blood during pregnancy. W. Neuweiler.
Studies concerning carbohydrate metabolism. Part I: Notes concerning
carbohydrate metabolism in the newborn. E. W. Winter.
Concerning the pathology and clinical features of carcinoma ot the ovary and
Fallopian tubes.
Concerning the peat pyromonter, with a note concerning ‘the mode of opera-
tion of peat baths. E. Wehefritz and E. ‘Gierhake.
*Brenner’s tumours in the walls of large ovarian cystomata. Z. von
Szathmary.
“A conservative operation for benign cystic tumours of the ovary. B. Kriss.
Concerning rotations of the Fallopian tube alone. E. Mosettig.

A case of persistence of the Wolffian duct with aplasia of the kidneys and a
double uterus. E. Tscherne.

\ The hotmonal function of granulosa-cell tumours. H. Dworzak and K.
Podleschka.

The velocity of the circulation of the blood in normal and pathological
pregnancy, with a note concerning tests of cardiac function during preg-
nancy and before labour. W. Spitzer.

Experimental studies concerning temporary hormonal sterility (Haberlandt’s
method). G. O. Kramer.

The action of iodine and protargol on the mucous membrane of the uterus
and the proximal section of the Fallopian tubes. R. A. Tschertok.

Psycho-vegetative modification of the human gravid uterus. C. Ginella.

A reaction of pregnancy on the basis of general cell-stimulation. M. Popoff
and A. Dimitrowa. '

Congenital tumours of the buttock. B. Szendi.

Hormonal modifications of the mammary glands in the mouse, with a note
concerning the aetiology of Reclus’s disease. C. Wieser.

\ The genesis of Brenner’s tumours. E.G. Abraham.
‘The clinical features and histology of adenocystoma pseudo-mucinosum
ovarii malignum. E. Latzke.

Alterations of the suprarenal glands during pregnancy. H. Guthmann and
L. Voelcker.

The rapid test for pregnancy, with the use of mature mice. R. Bruhl and
K. Holistein.

Biolaktin in gynaecological and obstetric treatment, its bacteriological char-
acteristics and the technique of its preparation. A. N. Morosowa and
S. Zeitlin.

The employment of biolaktin in puerperal diseases. B. Azletzky and X.
‘Lewitzkaja.

The resutls of the use of biolaktin in ‘trichomonal vulvo-vaginitis ‘and
gynaecological diseases. R. Orlowa and M, Tomaschewitsch.

Experimental researches concerning the question of a menotoxin. A.
Mandelstamm, W. Tschaikowsky aud G. Bondarenko.

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ACUTE PURULENT ENDOMYOMETRITIS CAUSING SPONTANEOUS RUPTURE OF THE
UTerus.

A spontaneous rupture -of the lower part of the uterine body and upper
part of ‘the cervix was found in a multipara dying 15 minutes after an easy
and ‘speedy labour, the placenta being undelivered and the clinical diagnosis
acute cardiac failure. Microscopic examination showed extensive purulent
endonyometritis, probably of recent and exogenous origin, chiefly affecting
the isthmus uteri. The partial insertion of the placenta in the isthmus had
probably ‘facilitated the rupture.

THE QUESTION OF INTERRUPTION OF PREGNANCY IN PULMONARY TUBERCULOSIS
IN THE LIGHT OF THE MODERN TREATMENT OF PHTHISIS.

German opinion on this question is much divided, but during the past
five years the conservative standpoint has gained adherence as the improved
prognosis after pneumothorax has achieved more recognition. Divergent
criteria diminish the value of statistical compar‘sons; prolonged following-up
of individual cases, radiographically controlled, is of more value. In con-
junction ‘with (1) data concerning the course of the disease in non-gravid
phthisical persons with and without cavitation, and (2) statistical comparison
of the course of the disease after continuing and interrupted pregnancy,
the writer’s experience of sanatoria leads to the conclusion that pregnancy
and labour do not exercise a very considerable influence on the course ot
pulmonary tuberculosis: induction of abortion, in the vast majority of cases,
is unjustified. “With very few exceptions indeed the induction of abortion is
to be rejected, until modern therapeutic measures, especially artificial pneumo-
thorax, have been carried out. In many cases prolonged institutional treat-
ment, from eight to 10 months, is necessary and the infant should be isolated
from the mother so long as bacilli tuberculosis are present in the sputum.
A second pregnancy is undesirable in patients who have not been cured, but
sterilization is very rarely justified. Legal protection of the infant from the
asocial mother is called for.

DIFFERENTIATION OF HORMONAL SUBSTANCES BY THE REID-HUNT, ASCHHEIM
ZONDEK AND OESTROUS TESTS, ESPECIALLY IN THE FLUID OF OVARIAN
‘CysTs.

In the Keid-Hunt reaction a protective action against the toxic action of
acetonitril in the white mouse is taken as evidence of the presence of the
hormone of the thyroid gland; indirectly the thyreotropic principle of the
anterior lobe of the hypophysis, by stimulation of the thyroid gland, gives
a positive Reid-Hunt test. A modified Reid-Hunt reaction is given by
adrenalin. The Reid-Hunt reaction is obtainable by crystalline folliculin
and numerous preparations containing folliculin, and by fluid from non-
blastomatous follicular cysts. The same is true of the fluid of benignant and
malignant cilio-epithelial ovarian blastomata: these contain both anterior
pituitary hormone and oestrin. The fluid from pseudo-mucinous and
dermoid cysts gives a positive test, probably because folliculin is present.
The positive reaction given by the fluid of parovarian cysts is ascribed to
presence of antuitrin hormones, forthe oestrous test is negative. ©

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INSULAR FUNCTION AND FECUNDITY. , u

Successful treatment by insulin has been reported in both diabetic and
non-diabetic women with amenorrhoea. Liegner reduced insular function to
a fraction by partial resection of the pancreas in guinea-pigs and found their
fecundity diminished by 80 per cent, compared with control animals: ovarian
atrophy was noted, with follicular persistence and atresia. Liegner suggests
that one type of sterility may be due to diminished insular function and may
respond to insulin-therapy. Clinically, the patient concerned is small and
slender, with an excellent appetite, yet of less than the average weight; she
either menstruates normally, or has oligomenorrhoea or secondary amenor-
rhoea; and has normal genitalia or some cystic transformation of the ovaries.

THE GENESIS OF ADENOSIS ENDOMETRIOIDES IN LAPAROTOMY ScaRS.

In 80 cases (in the literature) of endometriosis of laparotomy scars the
foregoing operations had been 50 ventral fixations, 15 Caesarean sections, two
for perforated uterus, two for removal of the appendix, three tubal steriliza-
tions, one ovariotomy and one myomectomy. In the Ziirich material the
whole series of 43 cases of scar-endometriosis followed abdominal opening of
the uterus (40 cases, corresponding to six per cent of these operations in the
earlier months of pregnancy). The 43 endometrioid tumours, which were
removed, had no connexion with the serous epithelium of the peritoneum, or
with the genital organs. With one exception they affected one or both of the
outer angles of the transverse (Pfannenstiel’s) incision. These findings favour
the implantation theory; for in most of the 4o hysterotomies the decidua had
been removed by the curette, probably including portions of basalis, of which
the faculty for implantation has been proved.

AUTOCHEMICAL MODIFICATION OF THE CERVICAL SECRETION.

The alkaline quotient of the cervical secretion is normally about pH 8.2
(shifting, according to Dietl, less than 1.0 towards the acid side during the
premenstruum). Increased acidity (pH 6.5) kills spermatozoa within a few
seconds and stops multiplication of Neisser’s coccus. Polano (Miinch. Med.
Wschr., 1931, No. 32) introduced gynan, the pH of which is 4.6, with the
purpose of acidifying the cervical secretion. The chief constituent of gynan
is salicylic acid. By the application of a tampon impregnated with gynan
before hysterectomy Neurnbergk found that the pH of the cervical plug was
altered to 5.8 at the lower and to 6.8 at the upper end: the latter value was
attained in the epithelium. The therapeutic value of gynan is enhanced by
combination with diathermy.

PRIMIPARAE IN THE FIFTH DECENNIUM.

In giving an account of 151 labours between the ages of 40 and 50 at
Miinich, the writers note that since the war the percentage has doubled.
These primiparae show no greater incidence of nephropathy than those be-
tween, the ages of 30 and 4o, but the greater frequency of morbid conditions
of the heart constitutes a serious danger. Premature labour is frequent (one
in six cases), but abnormal presentations are not more frequent than between
the ages of 28 and 40. The average duration of labour is little longer than

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that in primiparae of the previous decennium: early rupture of the mem-

. branes oecurs in one out of 3.5 cases, but uterine inertia is not abnormally

common. Injuries to the soft parts are frequent, but not more so than
between the ages 30 and 4o. In this series operative delivery was done in
one case out of three, delivery by the forceps in one out of six—approximately
the proportions in the primiparae aged from 34 to 40. One child in 5.5 did
not survive labour, but unduly high figures for length, cephalic circumference
and weight were not noted. The avoidance of Caesarean section is recom-
mended: other observers have reported high rates of mortality in aged primi-
parae and the Miinich figures show four deaths out of 13 cases.

BRENNER’S TUMOURS IN THE WALL OF LARGE OvARIAN CySTOMATA. «ii

Five cases, recognized during 15 years at a clinic in Budapest, are described.
A typical solid tumour was not encountered, the epithelial ducts being found
in four cases in the wall of large pseudo-mucinous cysts and once in that of a
simple serous cyst. The tumours thus corresponded to the second, and
smaller, group of Robert Meyer’s classification of Brenner’s tumours. The
five tumours varied in size from that of a hazel-nut to that of a large coconut.
Brenner’s tumours, in sharp contrast with granulosa-cell tumours, are clinic-
ally benignant and, apparently, do not alter the uterus or its menstrual func-
tion, although a myoma is not an uncommon accompaniment. In three cases
v. Szathmary could trace connexion between the cellular elements of the
epithelial ducts of the tumour and the epithelium of the multilocular cystoma.
He concludes that an origin from indifferent epithelial elements of Walthard’s
cell-group is probable.

CONSERVATIVE OPERATION FOR BENIGN Cystic TUMOURS OF THE Ovary.
After describing the various techniques which have been propounded for
the preservation of ovarian tissue, after unilateral ovarian excision, as well
as after bilaterai excision, and after alluding to the occasional formation of a
neoplasm in ovarian remnants, Kriss reports a series of 106 conservative
operations for one or two ovarian tumours—7o follicular cysts, 12 dermoids, 11
tubo-ovarian cysts and five chocolate-cysts, as well as eight cases of bilateral
pseudo-mucinous cysts in young subjects. When macroscopically no remain-
ing ovarian tissue was visible a portion of juxta-hilar tissue was dissected -
out and left; this was necessary in 43 cases. One of five patients, pregnant
at the time of operation, aborted: tour of the others subsequently bore chil-
dren. Menstruation, in patients aged less than 45, returned from one to 18
months after operation in about three-quarters of the patients who could be
traced. Subsequent operations for new cysts were done in three cases: in two
the cyst had formed in the organ which was healthy at the first operation.
W. E. Crowther.

Miinchener Medizinische Wochenschrift.

No. 5, February 2nd, 1934.
*The use of a girdle to facilitate birth—a custom in the life of peoples. G.
Buschan. \

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No. 6, February 9th, 1934.

“On spontaneous fractures of the neck of the femur after treatment of
uterine carcinoma by the X-rays. L. Kropp.
*The use of the electric aspirator in gynaecology. B. Lérincz.

Tue Use oF A GIRDLE TO FacILirateE BirRtTH—A CUSTOM IN THE LIFE OF
PEOPLES.

Among the numerous magic and mystic appliances to make pregnancy
and birth easier, the use of the girdle of a holy person played a large part in
the Middle Ages, especially among the members of the Catholic Church. A
special power of healing was believed to reside in articles which belonged to
St. Mary, St. Margaret and St. Elizabeth. In France, the girdle or belt of
the Virgin Mary was very highly esteemed. The author states that repro-
ductions of it are to be found in various convents, as at the Convent of Puy-
Notre-Dame in Anjou. These belts were made by the nuns from white
silk, which had been made holy by contact with a remnant of the belt of St. -
Mary. They were loaned to nunnery pupils who had married, and they
generally bore the inscription ‘‘Our Lady, protect us.’’ A holy belt was
frequently given to noble ladies, and it is stated that one was used by the
wife of Louis XII. In England, the belt of St. Mary was highly esteemed
by the aristocracy at the beginning of the sixteenth century. When the
nunneries at Leicester were dissolved, 11 such girdles were found. The
practice was also employed by the nobility in Hungary, where the belt of
St. Margaret was introduced in the seventeenth century. In order that the
belt should not be lost during transport to various homes, it was conveyed
under military protection and similarly restored. This made its use expen-
sive, and so only wealthy people could afford to have its assistance. The
girdles of certain male saints, also, were believed to be helpful in parturition,
and they are said to have been used in Babylonian times. At the present
time, among certain primitive races} e.g. Polynesians, Burmese and Chinese,
the use of a magic girdle for women in labour may be encountered. Buschan
states that there is no medical explanation for the practice, and that the
bandaging of the abdomen of a woman in labour, sometimes employed at the
present day, is scarcely applicable to primitive peoples. He suggests that it
is associated with superstition and myth, and that the function of the girdle
was to frighten or to catch evil spirits.

On SPONTANEOUS FRACTURES OF THE NECK OF THE FEMUR AFTER TREATMENT
OF CARCINOMA OF THE UTERUS BY THE X-RAYS.

Baensch, Philipp, and others, have recently described several cases in
which spontaneous fracture of the neck of the femur has occurred after treat-
ment of carcinoma of the uterus by the X-rays. Other processes which
notoriously lead to spontaneous fractures (syphilis, osseous metastases, osteitis
fibrosa and other destructive and neuropathic diseases of bone) could not be
held responsible. Only old age could be regarded as a predisposing factor
in several of these patients. As an alternative explanation was lacking, the
authors assumed that they were dealing with damage to bone caused by the
X-rays. Even if one remembers that osseous tissue is one of the tissues

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least affected by X-rays, this suggestion is not to be rejected. Vascular
damage may first occur, which may lead to atrophy in the neck of the femur,
Anatomical examination of the bone would be necessary to settle this ques-
tion. Kropp reports a case in which spontaneous fracture of the neck of the
left femur occurred under conditions similar to those mentioned above. The
patient, aged 67 years, had normally given birth to 10 children; the menopause
occurred at the age of 49 years. Wertheim’s operation was performed for
carcinoma of the portio vaginalis cervicis: the patient was subsequently
treated with X-rays and radium. Radium was applied three times and the
X-rays six times. Three years later she suddenly felt intense pain in the left
thigh, following which she walked with a limp. An X-ray photograph
showed an intracapsular fracture of the neck of the left femur. There was
no suggestion of metasasis and no callus. Atrophy of the bone was detectable
when a comparison was made with the right femur.

Kropp states that to assess the participation of X-rays in the development
of such a fracture one has to bear in mind the fact that spontaneous fractures
may occur in old age, when they are favoured by fragility of the bones.
Fracture of the neck of the femur 1s regarded as the classical example of senile
fractures, the principal cause being the weakening of the trabecular system
by senile osteoporosis and the reduction of the angle between the neck and
the diaphysis of the bone. Accordingly attention has to be paid to the
slightest of injuries. The author states that there was no history of injury
in his case. Nevertheless senile changes must be considered, even if they are
not detectable in an X-ray photograph. He believes that the method of
irradiation which he employs is not dangerous, but that the possibility of
spontaneous fracture after X-ray treatment should be borne in mind.

THE Use oF THE ELEcTRIC ASPIRATOR IN GYNAECOLOGY.

The author describes an apparatus for obtaining material for the purposes
of examination from the cavity of the uterus. The apparatus consists of a
simple motor-pump, interposed into an electric circuit, and a glass cannula
which is introduced into the uterus. The particles of tissue aspirated from
the cavity of the uterus reach a glass vessel through this cannula. The glass
tube is connected to the motor-pump by means of thick-walled rubber tube.
In multiparae the cannula may be introduced without previously dilating the
cervix, but in nulliparae the cervix must be dilated to admit Hegar’s number
five dilator. This form of electric aspirator is not a new apparatus in
medical practice, having been used by laryngologists for a long time. Lérincz
has made the apparatus in the belief that in the future it will take the
place of diagnostic curettage, which may be dangerous. He employs aspira-
tion in cases in which there is a suspicion of extra-uterine pregnancy, in
haemorrhage of unknown cause and when the action of hormones on the
endometrium is to be studied. He describes its use in several cases of ectopic
ptegnancy in which it has been employed. He concludes that the uterine
aspirator is a useful instrument in all cases in which curettage, performed for
diagnostic purposes, may be dangerous. Its employment is harmless if the
necessary asepsis is observed.

A. Sharman.
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Zentralblatt fiir Gynakologie.

No. 4, January 27th, 1934.
PROCEEDINGS OF THE GERMAN GYNAECOLOGICAL SOCIETY IN BERLIN, OCTOBER
IITH TO I4TH, 1933.

Medical interference on account of eugenics. Fischer.

How can gynaecologists help to prevent inherited diseases? Seitz.

A new method of operation for prolapse. Kovacs.

Operative and hormonal treatment of true hermaphroditism. Naujoks.
An electro-mechanical recorder of the uterine contractions. Rech.
The question of periodic sterility of women. Albrecht.

Hormonal sterilization. Lotze and Schultz.

The permanence of Madlens’s tubal sterilization. Saenger.

ORIGINAL COMMUNICATIONS.

~ Malignant granulosa-cell tumour and sexual precocity. Saenger.
Leiomyoma of the small intestine. J. S. Schapiro.
A new method of operation for prolapse. Fr. Kovacs.
A modified method of forming of an artificial vagina using the large intestine.
A. Mandelstamm.
Twilight sleep induced by dilaudid and scopolamine in operative gynaecology.
F. Jost.
*Two cases of pregnancy in the tubal stump. O. v. Schroeder,

No. 5, February 3rd, 1934.

PROCEEDINGS OF THE GERMAN GYNAECOLOGICAL SOCIETY IN BERLIN, OCTOBER
IITH TO I4TH, 1933.

The development of the pelvis. Scipiades.

The problem of the onset of labour., Dryoff.

Labour as a process of work. Schroeder.

Mobility of the foetal spinal column. Liittge.

Results of the increased obstetric statistics in Hamburg. Heynemann.

Further clinical findings with the hysteroscope. Frey.

The peripheral circulation and pregnancy. Hansen.

The biology of the placenta. The vacular findings in the intervillous space
and the tissue-changes of the placenta. Franken-Krebs.

The significance of the maternal decidua for the regulated growth. of the
trophoblast between the chorionic villi. Neumann.

Is a certain amount of didactic teaching necessary in the teaching of mid-
wifery? Holzapfel.

Pregnancy and anaemia of pernicious type. Hoevelmann.

The objects and methods of future investigation on eclampsia. Rossenbeck.

The prophylaxis of eclampsia. De Snoo.

What indication is given by galvanic irritability in the recognition of
eclampsia? Spiegler.

The question of the treatment of eclampsia. Fauvet.

Living full-time foetus in extra-uterine pregnancy. Scipiades.

Marking of the newborn to prevent interchange. Kovacs.

Vesical endometriosis and endometriosis of the abdominal wall. Haselhorst.

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Adenofibrosis interna and externa in abdominal scars. Helm.

The frequency and actiology of occipito-posterior presentation. Siedentopf.

One thousand four hundred deliveries in cases of contracted pelvis. Dierks.

The early diagnosis of cervical carcinoma. Hinselmann.

The treatment of choice in carcinoma of the cervix. v. Mikulicz-Radecki.

Radio-therapy in the treatment of carcinoma of the cervix. Eymer.

The influence of the anterior lobe of the pituitary body upon carcinoma.
Gaessler,

The influence of lues and diabetes on the radio-sensibility of carcinoma oi
the cervix to radium. Kleine.

The duration of cure during the years 1913 to 1928 of cases of cervical
carcinoma treated in the Gynaecological Clinic at Breslau. Reiprich.

The results of old radiation of gynaecological carcinoma. Gdbel.

The comparative measurements of radium in thin-walled and thick-walled
chambers. , Keller.

The treatment of placenta praevia with forceps which make traction on the
skin. Gausz.

Obstetric forceps with a check screw. Lénne.

Hooked forceps for breech presentation. Kovacs.

The technique of Caesarean section. Daels.

Bacillus welchii in the vaginal secretion. v. Kreninger-Guggenberger.

Electro-coagulation with two active electrodes. Jonen.

Investigation of an ovarian substance with metabolic activity. Anselmiino.

The metabolic effects of the hormone of the corpus luteum. Hoffmann.

Is it possible to separate the hormones which have effects upon pregnancy
by means of metamorphosis experiments? Kiistner.

What amounts of folliculin and androkinin are found in the excreta during
the normal menstrual cycle and after the administration of folliculin by
the mouth? Siebke.

The genital changes in the bat and attempts to influence them by the
administration of hormones. Caffier.

Modern ovarian hormonal therapy. Buschbeck.

Hormones, vitamines, cell-growth and carcinoma. Ludwig and Ries.

Vitamin E and hormone. Geller.

An experimental contribution to the question of vitamin E. Gierhake.

The: Aschheim-Zondek reaction after castration by radiation and operative
castration. Brandstrup.

Quantitative investigation of the hormones in the urine of sterilized women.
Damm.

Investigation into the pressure upon bladder, ureter and renal pelvis exerted
by genital tumours and pregnancy. Eufinger.

New lights on the investigation of twins. v. Verschuer.

The estimation of the hepatic function in emesis gravidarum. Schmidt.

Clinical and animal experimental investigations into the question of the
intentional influence of sex. Schumacher.

The resorption of sperms in women, who are otherwise healthy, with genital
disease. Ardelt.

Papillomatosis of the urinary organs and uretero-nephrectomy. Kneise.

Tranvesical drainage of the bladder. Daels and Elaut.

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JOURNAL OF OBSTETRICS AND GYNAECOLOGY

Further investigations into the arsenic content of the blood in women. and
the possibility of influencing it. Guthmann.

Observations on the hyperthermal bath after Linne. Schaefer.

Thermo-electric investigations into the action of physical influence on the
human organism. Schultze-Rhonhof, Rech and Kretzchmer.

The development of the fertilized ovum. Frommolt.

Chorea gravidarum. Déderlein.

Organisms of the vagina. Philipp.

Turning and extraction in transverse lie, perforation of the dead foetus.
Schultze.

ORIGINAL COMMUNICATIONS.

Statistics of peritonitis. G. Linzenmeier.
A contribution to the aetiology of uterine rupture. F. Athenstaedt.

"Is there danger in the use of sodium evipan in obstetrics? C. Holtermann.
The bearing of the Hofstatter-Cullen-Hellendall sign on the caput medusae.

H. Hellendail.

An experience in termination of pregnancy in a private house. F. Haller
Thyroid extract in threatened abortion. H. van der Hoeven.
The question of the legal sterilization of women. L. Daullig.
A portable pelvic cushion for domiciliary obstetric practice. R. Clarus.

No. 6, February roth, 1934.

The treatment of carcinoma of the cervix. H. Martius.

The technique of extraperitoneal Caesarean section. G. Kaboth.

“Rapid delivery at the end of pregnancy and during labour after Delmas, and
modifications of this method. A. Ostrcil.

The course of labour in old primiparae. E. Redenz.

The weight and length of twins. F. Ludi.

*The aetiology of transcervical fistulae. K. Welsch.

The complications of labour with yelamentous insertion of the umbilical cord.
H. Noldeke.

No. 7, February 17th, 1934.

Radio-therapy of cervical carcinoma. H. Martius and E. Witte.

Eclampsia simulating other diseases. R. Fikentscher.

An experimental contribution to the Reid-Hunt reaction with especial
reference to the sera and urine of pregnant women, and to the sera of
eclamptic and carcinomatous women. St. Sommer.

“An incident in the use of evipan. G. Redmann.

A new umbilical clamp. M. C. Boon v. Ochssee.

No. 8, February z4th, 1934.
The simultaneous occurrence of loops and true knots of the umbilical cord.
S. v. Wachenfeldt.
The gastric funetion during normal and pathological pregnancy. E. W.
Winter.
*Evipan in the gynaecological clinic and private practice. F. Meder.

No. 9, March 3rd, 1934.
How does secondary uterine inertia result from infection of the amnion?
E. Kehrer.
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The treatment of uterine perforation in abortion. S. Ernst.

The occurrence of large hepatic cavernous haemangiomata. J. Schulte.
Anterior pituitary hormone in the vaginal secretion. K. Fukushima.
Chemical extirpation of the uterus. The treatment of benign gynaecological
bleeding by cauterization of the endometrium instead of by hysterectomy
or radiation. A. Lehmacher.

No. 10, March roth, 1934.
The obituary of Otto Pankow. H.O. Neumann.
*The hormonal contents of cysts and tumours of the ovary. E. Philipp.
*The treatment of dermatitis during pregnancy. A. Lysander.
A case of mammary bleeding. B. Kaminsky.
A new contribution on the treatment of abnormal menstruation with para-
thyroid extract and calcium. G. Bakacs.
An operating table with an arm-rest for the new apparatus for intravenous
injection. G. v. Bud.

Two CASES OF PREGNANCY IN THE TUBAL STUMP.

Von Schroeder describes two cases in which removal of a Fallopian tube for
ruptured tubal pregnancy was followed by pregnancy in the same tubal stump.
The first patient had previously borne one living child before she had the
two succeeding tubal pregnancies. The second patient was operated on for
unruptured tubal pregnancy in June; in October of the same year she was
again operated on for a second tubal pregnancy in the interstitial portion of
the Fallopian tube of the same side. In this case the pregnancy and the
tubal mucous lining were excised; the funnel-shaped wound was closed with
through-and-through sutures. Eighteen months after her second operation
this patient gave birth to a living child at full time.

Is THERE DANGER IN THE USE OF SODIUM EvIPAN IN OBSTETRICS?

Holtermann refers to the satisfactory results he has obtained with the
use of sodium evipan for maternity cases during the past year. This drug
was given to several hundreds of patients to produce narcosis for operative
interference during pregnancy and labour. A few patients were delivered
by extraperitoneal Caesarean section with this form of narcosis alone; in others
it was used as a basal narcotic before the administration of some other
general anaesthetic. Owing to the short duration of the narcosis he has not
found it satisfactory for use in spontaneous delivery. In his own practice
two patients have died as a result of its administration. In the first case a
dose of only 4.5 cubic centimetres of a solution of sodium evipan was injected
before version for the correction of a transverse lie and prolapsed cord in a
secundipara. This dose was not more than 1.5 cubic centimetres above
the ordinary soporific dose. As the patient was restless she was given from
10 to 20 minims of chloroform until a further solution of evipan could be
obtained. Fifteen minutes after the first dose the sleepy patient was given
seven cubic centimetres of evipan, the effect of the previous dose having,
apparently, worn off. Immediately after the second dose the patient became
livid; the pulse became small and scarcely perceptible; respiration was
arrested; and the pupils became widely dilated. Version and extraction of the
foetus were carried out with great speed; artificial respiration was begun and

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an injection of three cubic centimetres of coramin was given to the patient.
Spontaneous respiration returned after 10 minutes and the patient’s colour
became good. She slept for an hour and a half and had no untoward effects
during the puerperium.

In the second case the patient had a prolonged labour in which the tem-
perature and pulse-rate rose after 40 hours and the foetus died in utero. The
temperature remained high for five hours and then dropped. After 50 hours
the labour was terminated by perforation of the head and extraction under
narcosis induced by sodium evipan. The patient was given an initial dose of
six cubic centimetres; on account of great resistance on the part of the
patient a second dose of four cubic centimetres was given. This was followed
by cyanosis, vomiting and cardiac failure. In spite of treatment, continued
for two hours, the patient remained unconscious and died.

The writer ascribes the alarming symptoms in his first case to overdosage
in a healthy patient, because the onset of symptoms immediately followed the
second dose of evipan. In the second case there was an interval of about 15
minutes before the grave symptoms appeared; hepatic and cardiac changes,
showing the presence of a preceding toxic condition, were found post-mortem.

Although the author has not regarded nephropathy, eclampsia and pre-
eclampsia as contra-indications to the use of evipan, after an experience of
more than 1,000 cases, he considers that a rise of temperature during labour
was a contributory cause of death in one of his fatal cases.

Rapip DELIVERY AT THE END OF PREGNANCY BY THE METHOD OF DELMAS.

Ostrcil of Prag reviews the results published by Delmas in his own cases,
which numbered 124 out of a total of 2,800. In 60 per cent labour had not
started, and in all cases in which the foetus was living at the beginning of the
procedure a living child was delivered. The maternal results were good in all
cases except one in which the mother died of septicaemia.

In addition to cases of Delmas some 30 French writers have published a
total of 120 cases; in these the results were not nearly so satisfactory. There
were 24 cases of deep cervical laceration, two of complete laceration of the
perinaeum, two of vaginal Caesarean section, two of ruptured uterus, and in
three cases dilatation was not obtained. The after-results were also poor.
There were eight maternal deaths, nine foetal deaths and two cases of
phlegmasia alba dolens.

Seven of the writers considered the method to be definitely dangerous,
15 held that there was a place for this procedure with very circumscribed
limits for its indication and six recommended it for universal use. The writer
has employed this method in six primiparae and 15 multiparae. He considers
that it is only to be used when an inhalation anaesthetic is definitely contra-
indicated, as by cardiac failure, and in the presence of an urgent reason for
rapid evacuation of the uterus. In his cases he used a minimal amount of
anaesthetic beginning when the cervical canal was completely taken up.
Unlike Delmas, he prefers not to perform version before the extraction of the
child, but to follow the dilatation by the intravenous administration of one or
two drops of pitocin to induce spontaneous expulsion, or to deliver by means
of the forceps.

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THE AETIOLOGY OF TRANSCERVICAL FISTULAE.

Welsch describes two cases of transcervical fistula which have recently
come under his notice. In the first case the patient was bleeding severely from
the uterus at the eighth week of pregnancy. The vaginal portion of the
cervix was very long and conical and its rigidity was such that it was deemed
undesirable to attempt rapid dilatation and evacuation. The cervix was,
therefore, dilated to admit Hegar’s number 8 dilator, two laminaria tents were
inserted into the cervical canal and the vagina plugged. The subsequent pains
were so severe that it was quite impossible to keep the patient in bed; 17
hours later the patient was examined. Atter removal of the packing the
external os was found not to be dilated and only contained the two threads
which were tied to the ends of the tents which had completely disappeared
inside. The other ends of the tents had perforated the posterior cervical wall
and were protruding through the opening into the posterior vaginal fornix.
The free ends of the tents were grasped with bullet forceps and drawn
through the opening leaving a hole which admitted one finger. The ovum was
evacuated through this hole by means oi ring-forceps and a blunt curette.
The bridge between the two openings was divided to allow of better drainage
and healing by granulation.

The second patient was aged 31 and had been married for a year without
becoming pregnant. Four years before she had been treated, by a well-
known gynaecologist, for severe dysmenorrhoea by the repeated introduction
of a laminaria tent. On examination for her sterility a perforation was found
in the posterior wall of the cervix; it was easy to pass a sound into the uterine
cavity through this opening. As in the former case the bridge between the
fistula and the external os was divided. The writer suggests that in both
cases the tents became dislodged in an upward direction because the patients
were allowed to move about; that when the uterine contractions began the
lower ends of the tents were pressed against the posterior cervical wall so firmly
that pressure necrosis resulted with the escape of part of the tents through
the necrotic tissue. Three other cases of similar cervical rupture have been
recorded by Blumreich, Caffier and Schénholz, respectively, and in each case
laminaria tents had been used.

AN ANAESTHETIC INCIDENT DURING THE UsE oF EvIPan.

Redmann refers shortly to cases, previously recorded by other writers,
in which the use of evipan has been followed by untoward symptoms, or
death. He describes the case of a patient who was apparently healthy except
for a markedly kyphotic spine and distinct hairiness of the arms and legs. He
decided to operate for an inevitable abortion at the tenth week of gestation
and to use evipan. Eight cubic centimetres of a 10 per cent solution were
injected into a vein in the arm during one minute. The patient began to sleep
after five cubic centimetres had been injected, and she was fast asleep when
she had received eight cubic centimetres. Within 20 seconds of the end of the
injection her respiration became very shallow, the pupils widely dilated, the
pulse-rate rapid and its volume small. After 10 more seconds respiration
stopped and the pulse became still more feeble. Artificial respiration was
carried out and an intravenous injection of 5.5 cubic centimetres of coramin
was given. Since improvement did not follow the injection of coramin one
cubic centimetre of lobelin and two cubic centimetres of hexetton were given

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intramuscularly, followed by 5.5 cubic centimetres of coramin, five cubic centi-
metres of camphor and one cubic centimetre of cardiazol. Six minutes after
the last injection the patient began to breath feebly and irregularly, the
pupils were less dilated and the cyanosis was less marked; but she was dis-
tinctly pale and consciousness had not returned. The uterus was quickly
evacuated and the patient returned to bed with hot water bottles and radiant

heat. After an hour and three-quarters she began to respond to external

stimuli and breathed more deeply, although she immediately went to sleep
when undisturbed. Four hours later she awakened, remained very pale and,
for 24 hours, complained of severe headache. Eight days later she had severe
lumbar pain and headache. The urine contained numerous erythrocytes,
granular casts, and a trace of albumin. The urine became normal after two
weeks of strict rest in bed, and the patient left the hospital apparently well.
The writer has seen three other cases in which evipan has been followed on
the eighth day by similar renal disturbances. The fright received by the writer
in this case has made him more careful in the use of evipan, which he had
previously considered entirely satistactory.

EvIPAN IN THE GYNAECOLOGICAL CLINIC AND PRIVATE PRACTICE.

Meder from his experience in private practice considers evipan a safe
narcotic to recommend to the private doctor for use in minor gynaecological
operations such as curetting, cervical dilatation, perinaeal suture and examina-
tion under anaesthesia. He considers that a dose of seven cubic centimetres
can be given with perfect safety, even to a patient whose stomach is loaded.
The injection of each cubic centimetre should occupy from a quarter to half
a minute. Consciousness returns from 15 to 20 minutes after the injection of
this dose of evipan. He has only had two cases which caused him any
anxiety. Both patients were anaemic women to whom 1o cubic centimetres
of the drug were given; respiration ceased and the pulse became weak for 10
minutes; recovery followed the, administration of carbon dioxide. He con-
siders that there is no danger in using seven cubic centimetres of evipan as an
anaesthetic, if highly nervous, cachectic and markedly anaemic patients are
excluded.

THE HORMONAL CONTENTS OF CYSTS AND TUMOURS OF THE Ovary.

Philipp states that ovarian tumours regularly contain the ovarian hormone
and prolan during pregnancy. Parenchymatous cysts of the ovary regularly
produce the ovarian hormone, and in these cases there is a disturbance of
menstruation. The urine need not necessarily contain the ovarian hormone.
Bleeding in association with ovarian cysts which contain folliculin can be
combated by the administration of the hormone of the corpus luteum. The
ovarian hormone can never be detected in serous cysts, so that Robert
Meyer’s denial that the serous cysts arise from the follicle receives some
support on hormonal grounds. The other new growths of the ovary, with
the exception of the granulosa-cell tumour, do not produce a_ follicular
hormone.

THE TREATMENT OF DERMATITIS DURING PREGNANCY.
Lysander describes the occasional occurrence of cutaneous lesions during
the course of pregnancy and the misery of those suffering from such conditions.

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REVIEW OF CURRENT LITERATURE

He considers that these cutaneous manifestations are the result of a toxic
effect of the ovum on the mother. There are two main groups of cutaneous
conditions occurring during pregnancy; the more common being erythema,
urticaria and pruritus: the less common, herpes gestationis. Many forms of
treatment have been adopted at different times with varying degrees of
success and failure. During the year 1932 the writer has treated 28 cases at
the Giteborg Clinic by the injection of the patients’ own blood. The blood is
withdrawn from the antecubital vein and held in the syringe until coagulation
has just begun when it is injected into the gluteal region. The first 11 cases
were given from 15 to 20 cubic centimetres, the later cases an initial dose of
one cubic centimetre and later doses of 1.5 cubic centimetres, two cubic centi-
metres and three cubic centimetres. The most satisfactory interval between
the injections was two or three days. The first cases were admitted to
hospital for treatment, but the later cases were treated as out-patients. The
results obtained were most satisfactory; 17 patients had only one injection;
six had two injections; one had three, and two had four and five respectively.
The disease recurred in two cases; one of these recovered after one more
injection, while the other was not seen again. Six patients had intractable
vulval itching, three of these transiently had sugar in the urine.

R. H. B. Adamson.

Acta Obstetrica et Gynegcologica Scandinavia

Vol xiii, Fasc. 4.

Primary polyhormonal amenorrhoea and glandular cystic hyperplastic
mucous membrane. Bernard Zondek.

Gastric perforation in conjnuction with closely approaching delivery, with
some remarks on cancer and ulcer of the stomach as complications of
delivery. Otto Groéne.

‘The nature of virilizing ovarian tumours. Hilding Bergstrand.

Cyclical changes in the Fallopian tube in human beings and the lower
primates. B. H. Jagerroos.

*A contribution to the question of the operative treatment of genital prolapse.
Gideon Ahltorp.

THE NATURE OF VIRILIZING OVARIAN TUMOURS.

Bergstrand describes four specimens of ovarian tumours which have come
into his possession and also the microscopic examination of two others known
as Berner’s and Strassmann’s cases. He has been able to prove that in two
of his own cases the tumours were folliculomata or granulosa-cell tumours;
because strands of the cells of this tumour form bodies resembling atretic
follicles. Histological analysis of the other four cases has led him to conclude
that, fundamentally, they are of the same nature. In one of these four he
has found an unmistakeable ovum in the centre of a large tumour. Granulosa-
cells, luteal cells, and cysts lined with columnar epithelium and containing
mucus were present in three cases. In two cases these cysts were distinct from
the ovarian clements of the tumour. He, therefore, considers that these

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JOURNAL OF OBSTETRICS AND GYNAECOLOGY

tumours were a combined malformation of the germinal epithelium of the
mesonephros and of the Wolffian duct or Miillerian duct. Clinically they
tend to be benign, if removed in time, although they contain mitotic cells and
show other signs of rapid growth. One of the author’s patients died of
secondary peritoneal growth.

Microscopic examination gave no evidence whether the active hormone
was produced by the granulosa-cells or luteal cells. Steinach and Kun, in
1931, were able to demonstrate the virilescent effect on the guinea-pig of an
extract of the corpus luteum, and they suggest that this is a function of the
corpus luteum. The author has not found any evidence to ascribe the
hirsutism occurring in these cases to the internal secretion of tumours arising
in a hypothetical testicular component of the embryonic ovary.

A CONTRIBUTION TO THE QUESTION OF THE OPERATIVE TREATMENT OF GENITAL
PROLAPSE.

Ahltorp makes an analytical review of the cases operated on for prolapse
during the years 1924 to 1931, inclusive, in the Gynaecological Clinic of the
Upsala Academic Hospital under the leadership of Professor John Olow.
During this period 104 cases were operated on for all degrees of prolapse and
of these about 75 per cent of the agricultural class. The operations employed
for all degrees of prolapse was entirely by the vaginal route, consisting of
anterior colporrhaphy, colpo-perinaeorrhaphy with suture of the levatores ani
muscles and amputation of the cervix, according to the extent of the genital
prolapse and condition of the cervix. He gives a minute description of the
steps of the operation with explanatory diagrams.

The local injection of a solution of novocaine, in the strength of 0.5 per
cent, was used in 38 cases; local anaesthesia was continued with general
anaesthesia with ether in 43 cases; ether was used alone in 12 cases; and the
method of production of anaesthesia is not stated in three cases. The ages
of patients varied from 20 to 79 years. In the author’s opinion old age is
not a contra-indication to an operation for prolapse, because local anaesthesia
can be wholly, or partly, employed. For describing the degree of the
prolapse a code was adopted by means of which each element could be speci-
fied, such as anterior vaginal wall, cervix and posterior vaginal wall with the
degree of descent, hypertrophy and lesion.

Ninety-five patients were subsequently examined about four years and
seven months after operation. Of these 86 were cured, two were improved,
and seven were not cured. Recurrence of the prolapse occurred when healing
by first intention had not occurred. The prognosis is better below the age
of 30 years and above that of 60 years than between the ages of 30 and 60.
A local anaesthetic has not any harmful effect on healing. Six patients
were delivered 11 times subsequently to operation with a return of some degree
of prolapse in two of these. Amputation of the cervix appeared to give rise
to premature delivery, in one patient four times, with survival of the children.
In conclusion the author considers that anterior colporrhaphy and colpo-
perinaeorrhaphy, combined if necessary with amputation of the cervix, are
satisfactory operations in the treatment for prolapse.

R. H. B. Adamson.

482

REVIEW OF CURRENT LITERATURE

Annali di Ostetricia e Ginecologia

January 1934.

Culture under glass of human placenta. Note 1. Research on the biology
and mode of growth of chorionic villi. Sannicandro.

*Clinical statistics of 22 cases of recurrent extra-uterine pregnancy. Torre.

The presence of basal cells in uterine cylindrical epithelium. De Maria.

*Insufflation of the Fallopian tubes in sterility. Mammana.

*Cuneiform resection of the uterus in the surgical treatment of inflammation
of the adnexa. Giordanengo.

CLINICAL STATISTICS OF 22 CASES OF RECURRENT EXTRA-UTERINE PREGNANCY.

It has been affirmed by several authors that there has been a progressive
increase in the incidence of extra-uterine pregnancy during recent years.
Some hold that this is due to the increased use of contraceptives and to the
number of cases of provoked abortion.

Torre cites clinical statistics in the Milan Hospital from 1927 to 1932.
In six years he had 482 cases of extra-uterine pregnancy out of 39,314
women admitted (1.1 per cent). In the two years 1931 and 1932 there
has been a diminution. On the other hand, cases of recurrent extra-uterine
pregnancy have increased. He has observed recurrence in 22 of the 482
cases, i.e. about 4.78 per cent, an approximation to the average number
given by other authors. Deleting cases which died, or which he could not
trace, this percentage rises to 6.35.

He describes in detail the clinical history and treatment of his 22
recurrent cases. His experience leads him to conclude that:

1. Recurrence affects women in full sexual life.

2. Preceding inflammatory lesions were present in 22.27 per cent of his
cases and, in most, were puerperal or post-abortional. The influence of
infective maladies, such as typhoid fever, cannot be denied. A number of
the patients had had typhoid fever. He notes that another physician,
Arcieri, had observed this antecedent. A cause for the first extra-uterine
pregnancy could not be found in 31.8 per cent of the cases, and for the first
or second in 4.54 per cent.

3. In 59.07 per cent the first extra-uterine pregnancy, whether the
patient was operated on or otherwise, seemed to affect the opposite adnexa
and favour recurrence. This occurred more frequently, however, after
medical treatment. :

4. Only 9.09 per cent of the patients had a uterine pregnancy between
the two ectopic gestations.

5. The period of relative sterility between the last uterine pregnancy
and the first ectopic one averaged five years. The usual average time to
clapse between two ectopic pregnancies was three years.

6. The mortality for the first extra-uterine pregnancy was 2.49 per cent:
for the recurrent 4.54 per cent.

7. Treatment should, so far as possible, be conservative, but have regard
to the adnexa of the other side and the condition of the patient after the
first operation.

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INSUFFLATION OF THE FALLOPIAN TUBES FOR THE DIAGNOSIS AND CURE OF
STERILITY.

The cause of sterility has often been a difficult gynaecological problem,
but within the last 10 years two new methods of exploration, the insufflation
of gas into the Fallopian tubes and hystero-salpingography by means of the
X-rays, have revealed that the origin of the trouble is often tubal and not
ovarian or uterine.

Mammana reviews the first attempts by Rubin, of New York, to create
a pheumo-peritoneum so that radiography of internal genital organs should
be possible. He then describes the latest apparatus and methods of insufflation
employed in Paris by Faure and Douay. The signs of permeability either in
one or both Fallopian tubes are well marked. The operator must note a fall
in the manometric pressure and listen for the souffle, which is best heard with
Doay’s bilateral stethoscope, in the ovarian region. Alternate compression of
one or both tubes of the stethoscope distinguishes which Fallopian tube is
pervious and which blocked. The disappearance of the hepatic dullness, duc
to sub-diaphragmatic accumulation of gas, should also be looked for, as well
as characteristic pain in the right shoulder, left shoulder, or both shoulders.
This is the most certain sign of permeability. The best time for insufflation is
five or 10 days after menstruation, when haemorrhage has ceased and ovu-
lation has not occurred. Its chief indication is sterility without apparent
cause with a normal and clinically healthy uterus and adnexa.

Contra-indications to the method are (a) uterine haemorrhage, (b) evident
uterine or adnexal infection, (c) any febrile state, (d) incipient pregnancy.
The dangers of the operation are:

1. Gas embolism. This risk undoubtedly exists, but a few precautions
before examination and careful observation of the patient during examination
make the risk very small. Re-absorbable gas, such as oxygen or carbonic acid
gas, should always be used and insufflation should never be carried out under
anaesthesia which might mask the first signs of embolism.

2. Infection due to the gas driving septic particles from the cervix into
the uterine cavity. Sepsis is a contra-indication to the employment of th»
method. Previous disinfection of the cervical canal and the avoidance of
abrupt changes of pressure are sufficient to avoid this risk in any normal case.

3. Rupture of the Fallopian tube. The pressure should never exceed 220
millimetres of mercury. Usually a pressure of 150 millimetres is sufficient.

4. Respiratory syncope is never a serious symptom; it may be avoided by
limiting the quantity of gas injected to 150 cubic centimetres.

The results of insufflation are two-fold, first, according to Graff, the site
of obstruction can be located in 50 per cent of the cases. Secondly insufflation
alone often removes a slight obstruction, e.g. a kink of the Fallopian tube,
mucus in the Fallopian tube; it has, therefore, a therapeutic value.

CUNEIFORM RESECTION OF THE UTERUS IN THE SURGICAL TREATMENT Oi

INFLAMMATION OF THE ADNEXA.

Since the recommendation of Tweifel, in 1899, surgeons have been accus
tomed to conserve part of an ovary, when operating for inflammation of the
adnexa, in order to avoid the symptoms of a premature menopause. Subse-
quantity it was found better also to leave part of the uterus, grafting ovarial

484

REVIEW OF CURRENT LITERATURE

tissue on to the uterine stump. Total removal of the uterus usually leads to
ovarian atrophy; sometimes to pain, so severe that a second operation for its
removal is required.

Salpingectomy with cuneiform resecticn of the uterus dates from these
discoveries and is the method of choice, employed with great success by
Lecéne, D’Allaine, and others in France and by Blair Bell in England. In
their opinion that part of the uterus which is the usual site of the origin of
endometritis and polypi is removed by cuneiform resection; thus extensions
to the cervix are prevented or healed. Lecéne employed the operation in
non-suppurative bi-lateral inflammation of the adnexa in which an entire
ovary, or part of an ovary was healthy. Blair Bell, Bentner, and others
extended the method, with success, even to suppurative conditions.

Giordanengo describes the technique of the operation as carried out by
himself in his hospital at Turin. He operated on 45 cases, but as he has not
had recent news of six cases, he gives an account of 39, dividing them into
three series.

1. Cuneiform resection of the uterus with bilateral salpingectomy and
vemoval of one ovary. This operation was performed in 24 cases; in seven
pus was present and in one the condition was tuberculous.

2. Cuneiform resection of the uterus with bilateral salpingo-odphorectomy
and the grafting of part of an ovary on to the uterine stump. This operation
was performed in 10 cases. In one case the graft failed

3. Cuneiform resection with bilateral salpingo-obphorectomy. This opera-
tion was performed in five cases. In all he obtained complete suppression of
endometritic foci and purulent vaginal secretion. There were no deaths in
the 45 cases treated. Menstruation returned in 20 patients in the first group
and in eight in the second. .

The author found that the two greatest dangers, haemorrhage and sepsis,
consequent on opening the uterine cavity, did not occur even without ligatur-
ing the uterine arteries or covering the uterine stump with peritoneum. He
considers that this operation is simple and not dangerous: it possesses advan-
tages over bilateral salpingectomy and sub-total hysterectomy by suppressing
endometritic foci in the fundus uteri and preventing the cervical inflamma-
tion which follows, while the reduced volume of the uterus enables that
organ to keep its physiological position without artificial aid. It permits intra-
uterine ovarian grafting, if this is necessary. Moreover it preserves the
menstrual cycle.

J. H. Filshill.

Revista Italiana di Ginecologia.

December, 1933.
“Early spontaneous rupture of membranes. Scarpitti.
*Pregnancy and norma! parturition shortly after complete cuneiform resec-
tion of the fundus uteri. Bozzolo
Morphological and secreting changes in the hypophysis of women suffering
from ovarian and uterine tumours, Forlini and Dondoli.

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The influence of folliculin and blood-serum of pregnant women in experi-
mental intra-uterine neoplasms. Giornelli.

Glucose-insulin-therapy in cardiac lesions during pregnancy. Consoli.

January, 1934.

Morbid conditions during pregnancy in relation to the maternal and foetal
glycaemic content. Rao.

Leucoplakia and cancer of the portio. Puccioni.

Central nervous lesions in pregnancy. Bacialli.

EarLy SPONTANEOUS RUPTURE OF THE MEMBRANES.

Scarpitti discusses prevalent views on the cause of early rupture of the
membranes, the efficacy of the membranes as a mechanical dilating agent and
a barrier against infection. Delay in parturition after early rupture of the
membranes was formerly attributed to their early rupture; it is now thought
to be due to the same factcrs which cause rupture and spastic contraction
of the cervical canal. This often begins before rupture and persists, leading
to uterine inertia and prolonged labour. Nornial expulsion should result from
physiological antagonistic harmony of the two uterine segments, the contrac-
tions of the uterine body, being regularly followed by relaxation and dilatation
of the lower uterine segment and cervix.

The real problem is to anticipate or cure spasticity of the cervix, and this
is the aim of Kreis’s so-called ‘‘medical delivery.’’ Early artificial rupture of
the membranes is the routine treatment in the medical school of Strasbourg.
Fatal consequences have not followed, the duration of labour is shortened,
operative intervention is unnecessary and sepsis is prevented.

Scarpitti describes 10 cases of early spontaneous rupture of the membranes,
attended by him in the Obstetric Hospital at Strasbourg and treated with
spasmalgin roche under the direct supervision of Professor Kreis. He also
describes two cases in which anticipatory artificial rupture of the membranes
was carried out. In these the duration of labour was shorter. From Kreis’s
statistics, the average duration of dilatation after artificial rupure of the mem-
branes was six or seven hours,

In the 10 cases in which spontaneous rupture occurred—in most before
admission to hospital—Scarpitti demonstrates, case by case, the method of
regulating the dose of spasmalgin according to degree of spastic cervical con-
traction. He thus proves that by the use of this antispasmodic remedy the
time of dilatation was diminished to about eight hours instead of 16 to 20
hours.

The spontaneous rupture determined only by thinness of the membranes’
(lilatation may take place as rapidly as after artificial rupture. In both rupture
occurs without, or preceding, spasms.

Scarpitti considers the duration of labour is a true prophylactic against
puerperal infection and maternal foetal death.

NORMAL PREGNANCY AND PARTRUITION ABOUT TWo YEARS AFTER COMPLELE

CUNEIFORM RESECTION OF THE FUNDUS UTERI.

Bozzolo has found no record in the literature of pregnancy taking place
after cuneiform resection of the fundus uteri for metritis and fibromata.
Recalling his own experience of the operation, he states that although he
obtained lasting cure of endometritis and fibroma in to young patients, preg-

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nancy did not subsequently occur. In this paper he describes an interesting
case of the eighteenth pregnancy in a patient aged 43.

In 1930 the patient came to hospital suspecting pregnancy nearly at term,
but the condition was found to be uterine fibroma with internal abortion at
the twelfth week of pregnancy. Laparotomy was performed and the diag-
nosis was confirmed. A voluminous wedge of uterine tissue, amounting to
two-thirds of the fundus, with disseminated fibroma was removed. Nine
months after the operation the patient again became pregnant. She entered
the hospital on 29th February 1932 and, two weeks later, gave birth to a
live male child. The scar of the iaparotomy had completely healed. The
puerperium was normal. Two months later the uterus was nearly its normal
size. Scarpitti shows three radiograms of the uterus taken after the injection
of lipiodol into the uterine cavity. It was noted that the uterine cavity was
not quite normal and regular. Parturition and the puerperium were normal.

J. H. Filshill.

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NORTH OF ENGLAND OBSTETRICAL AND GYNAECOLOGICAL
SOCIETY.

At the meeting of the North of England Obstetrical and Gynaecological
Society held at Manchester on Friday, January 26th, 1934, the Chair was
vacated by the retiring President, Professor LEYLAND RosInson, of Liver-
pool, and Professor Dante. DoucGaL, of Manchester, was installed as
President for the present year.

Dr. J. W. Brive, of Manchester, showed a specimen of
URETHRAL CyST.

The small specimen was a cyst which he had removed from the roof of
the urethra. It had not been opened, but probably contained mucus and
arose from the deeper portion of a gland in the sub-mucous layer. The
patient was a single woman of 31 years. She told him that ‘‘a lump had
suddenly appeared in the water passage a week previously.’’ There had
not been any pain on micturition or bleeding, but for a day or two she had
noticed a yellow discharge. On separation of the labia the small cystic
tumour in the urethral orifice was visible. Its covering of mucous membrane
had ulcerated, and the appearance was exactly like a cat’s eye looking out
of the urethra. He dissected it qut and the patient was able to go home in
a week. He had not previously seen a cyst arising from the roof of the
urethra, although cysts and abscesses of Skene’s tubules on the floor of the
urethra were not uncommon.

The PRESIDENT, Professor D. Dougal, described two cases. The first was
one of

A LarGE UTERINE FIBROID ASSOCIATED WITH TUBERCULOSIS.

The patient was a widow aged 44 years, who had had one miscarriage at
the fourth month of gestation 16 years ago, but no children Her menstrual
habit was 7/46 days with excessive loss and pre-menstrual dysmenorrhoea.
There had been seven months’ amenorrhoea. The Zondek-Aschheim test
was negative. She was a State Registered Nurse, who had been at Sheffield
City Sanatorium from 1914 to 1916 as a nurse; in 1921 she nursed at Baguley
for three months. Her health began to fail in 1915; she felt tired and
exhausted. She carried on till 1919 and then had one year’s rest. At Baguley
she was strongly advised to give up nursing, as her chest was suspicious.
From the age of 21 she had night-sweats and a regular winter cough. There
was not any haemoptysis. After leaving Baguley she went to Broughton
House Hospital for Soldiers for 10 years on night duty: she never had a

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night off for illness while she was there. She went home in 1931, since when
she gradually declined in health, losing six stones in weight during three
years. She now had dyspnoea, and her appetite was poor. From March
1933 she had pain in the right groin, stabbing in character, which improved
during the 10 weeks before operation. The loss of weight during 1933 was
two and a half stones. There was not any family history of tuberculosis.
At Manchester Royal Infirmary on November roth, 1933, Professor Dougal
performed panhysterectomy, removing both appendages. The uterus was
the size of a melon, and a tubo-ovarian abscess was present.

Mr. W. W. KING, of Sheffield, was interested in the distribution of the
tuberculous lesion in the uterus. Was there any in the capsule?

The President, in reply, said that the surface of the uterus was covered
with what appeared to be tubercles.

The President then described
A SEVERE CASE OF ENDOMETRIOMA.

The patient was a single woman of 37 years, complaining of dys-
menorrhoea and loss of weight. She had had an accident four years
previously and had broken her right radius; she did not work for 12 months.
At the time of the accident she weighed 12 stones, but soon afterwards
began to lose weight steadily, till at the time of being seen she weighed only
nine stones. Nausea had occurred at the menstrual periods for the last 18
months. In January 1933 she had influenza and latterly the menstrual
nausea had been associated with the vomiting of bile.

A general investigation was carried out by a physician for loss of weight,
nausea, and vomiting. Examination of the alimentary tract by the X-rays
was negative. A small mass was found in one groin.

At operation the bladder, ureters and the left ovary were found to be
involved in endometrioma. There was a nodule in the small intestine. Sub-
total hysterectomy with removal of the uterine appendages and appendix
was performed.

Mr. J. E. Sracey, of Sheffield, observed that in his experience endo-
metriosis was uncommon in the uterus.

Professor Mites Puitiips, of Sheffield, said his experience was to the
contrary. He thought that patients with tumours which were, clinically,
fibroids, who complained of excruciating dysmenorrhoea nearly always
had adenomyomata. He said that Cullen had found that 10 per cent to
15 per cent of specimens supposed to be fibroids were in fact adenomyomata.
A moderate percentage of patients with Schroeder’s syndrome had
endometriosis.

Dr. J. W. Brive, of Manchester, reported a case of
CARCINOMA OF THE CERVIX AFTER SUB-TOTAL HYSTERECTOMY.

He performed sub-total hysterectomy for a patient, M.B., aged 36 years,
in 1926 for chronic metritis and bilateral adherent appendages. The patient
was fat and the chronic inflammatory state of the Fallopian tubes made

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panhysterectomy impracticable. He saw the patient again in December
1933, when she was complaining of bleeding from the vagina; on removing
a piece of the cervix he found it, on microscopic examination, to be a
squamous-cell carcinoma. She had since had two applications of radium,
110 milligrammes, for 22 hours on each occasion, and was to have a third
application shortly, This was the first case that he had seen of carcinoma
developing in the cervical stump after sub-total hysterectomy. It was his
practice to perform panhysterectomy whenever the cervix was lacerated or
chronically inflamed. He added that, unfortunately, in many of those cases
in which one would particularly wish to perform the radical operation,
adhesions or infiltration existed which made one hesitate to add to the risk
of the operation, on account of the remote possibility of malignancy, this
being the first case he had had in 15 years of practice. There were several
points of interest in the history of this case. She was first a patient of
Dr. Donald in St. Mary’s Hospital, Manchester, in August 1924, when the
cervix was dilated and the uterus curetted for chronic metritis. In March
1925, the bleeding continuing, three tubes of radium (the dose is omitted
from the notes of the case) were inserted for 48 hours. In 1926 bleeding
was still troublesome: she saw Dr. Bride, and he performed sub-total
hysterectomy with removal of both appendages: he considered the previous
application of radium probably to be responsible for the infiltration of the
pericervical tissue, which made panhysterectomy impossible. After that
operation she was well until December 1933, and then, after six years, slight
bleeding started due to squamous-cell carcinoma. He concluded that the
risk of carcinoma developing in the cervical stump was very small: that the
malignant disease was a new development, not dependent on any condition

present at the time of operation, and that the radium was not a prophylactic
against carcinoma.

Discussion. The PRESIDENT said that he did total hysterectomy in
parous women with few exceptions. In difficult cases he thought that the
immediate danger from total hysterectomy was greater than the remote
danger of carcinoma developing in the cervix if sub-total hysterectomy was
performed.

Mr. A. GouGH, of Leeds, also made a rule of performing the total
operation in parous women. He had treated three cases of carcinoma in
the stump, one by a modified Wertheim’s operation, and two by radium:
he considered the latter to be the better treatment.

Dr. A. A. GEMMELL, of Liverpool, had treated two cases. One occurred
15 and the other 20 years after sub-total hysterectomy, which was
performed in one case for inflamed appendages, and in the other for cancer
of the uterine body. In both cases the growth was probably an entirely new
condition.

Professor MILEs PHILLIPs had had two cases, one nine and the other
20 years after the sub-total operation. Neither had had any children; both
had had one early abortion, and both responded to radium.

Mr. W. W. KincG said that if there was an argument against the sub-total
operation, there was a similar argument against the treatment of menor-
rhagia by radium.

Dr. Brive, in reply, said that, in many cases, especially in cases of

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inflamed appendages, it was not possible to remove the cervix with safety.
He thought that in future he might amputate the cervix from below in
such cases.

Dr. C. H. Watsu, of Liverpool, described a case of

HyYDRAMNIOS.

Mrs. J. McN., aged 25 years, had had four deliveries at term with four
normal living children. The youngest child was two years old. Her last
period was on January 7th, 1933, her expected date of confinement
October 14th. She attended the antenatal clinic at Smithdown Road
Hospital on October 1oth, i.e. at the thirty-ninth week by date. Her
general health was good, but there was a slight trace of albumin in the urine.
The size of the uterus corresponded to the thirty-sixth week of gestation;
the presentation a breech for which version was performed. Two weeks
later she attended the clinic, when the presentation was again a breech, and
an abnormality in the size of the uterus was not noted. She was admitted
to hospital on November 21st, 1933, i.e. five weeks post-mature by date.
On examination her general condition was good, and the abdomen, although
large, did not cause her discomfort. The uterus was distended with liquor
amnii, and sub-acute hydramnios was diagnosed. The foetal head could be
ballotted in the fundus, but could neither be grasped, nor its outline traced,
owing to the excess of liquor. An examination was, therefore, made by
the X-rays (Dr. Walsh showed two films at this stage); the films showed
ossification of the base of the skull with an indefinite outline of the vault.
The diagnosis was probably hydrocephalus, but anencephalus could not be
excluded. To establish the diagnosis conclusively the following technique
was used: 30 ounces of liquor amnii were withdrawn by tapping the uterus
with a lumbar puncture-needle through the abdominal wall, under local
anaesthesia with novocain. Sixty cubic centimetres of uroselectan were
then injected into the amniotic sac and the needle withdrawn. Further
X-ray photographs were taken (Dr. Walsh showed two more films at this
stage). The uroselectan could be seen surrounding the foetus, and the out-
line of the skull plainly seen. A diagnosis of hydrocephalus was readily
made. The patient started to have pains the same evening, November 23rd,
and delivered the foetus naturally as far as the umbilicus. Under general
anaesthesia the foetus was delivered easily after perforation of the after-
coming head. Convalescence was normal. She was discharged from hospital
on the fourteenth day after delivery.

This case serves to demonstrate several important points:

1. Every case of hydramnios should be examined by, the X-rays. If the
foetus is normal, liquor is withdrawn by paracentesis uteri, and the preg-
nancy allowed to continue.

2. If the foetus is abnormal, its outline can be demonstrated by injections
of 20 cubic centimetres of uroselectan (i.e. much less than was used in this
case) into the sac after withdrawing the excess of liquor. By this means a
certain diagnosis is made and labour is induced.

Mr. A. M. Crave, of Leeds, asked whether the intra-uterine injection of
uroselectan was an infallible method of inducing labour, and Dr. F. H.

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Lacey, of Manchester, asked if it enabled one to recognize the sex of. the
child.

Dr. Walsh, in reply, said that the sex was sometimes demonstrable, and
labour was induced in 95 per cent of the cases. The drug was harmless to
mother and child.

Dr. K. V. BatLey, of Manchester, read a paper on
THE LOWER SEGMENT OPERATION AS THE ROUTINE CAESAREAN SECTION.

He advocated the performance of the lower segment operation in all
cases in which abdominal delivery was deemed necessary, whether the
patient was in labour or not, whether she was potentially infected or other-
wise. He argued that it was a safer procedure with a smoother conval-
escence and a sounder ultimate result than the classical operation. He
made no attempt to review the history of the operation, but alluded, in
passing, to the papers of Munro Kerr, Schweitzer and St. George Wilson. -

Although the lower segment is only fully developed after labour has
begun, the part of the uterine wall through which the incision is made is
thinner than it is at a higher level even before labour: it is, therefore,
permissible to speak of the lower segment operation even when it is carried
out before labour. Dr. Bailey stressed this point because a large percentage
of his cases were operated on before labour, and it was this section of them,
rather than those operated on during labour, that demonstrated to him the
soundness of the technique. In his series 54 cases were in labour, and 65
not in labour. This included all cases operated on by him during the
previous four years, both in hospitals and nursing-homes. In reporting 55
cases operated on at St. Mary’s Hospital he was indebted to members of the
honorary staff of the hospital. During the ‘four years he had used this
technique exclusively without respect to the type, or state, of the patient.

Technique. After the usual’ preparation the patient is placed on the
operating table, and the operation is carried out with the patient in the
horizontal position. Even a modified Trendelenburg’s position may
embarrass the breathing, owing to the fundus uteri falling against the
diaphragm and so rendering the administration of anaesthetics difficult.
The weight of the uterine body pulling on the lower segment increases the
liability of the incision to split during extraction of the child. In Trendelen-
burg’s position, the extraction is made more difficult by being carried out
uphill: more force is required than in the horizontal position, and potentially
infected liquor and blood tend to flow downhill into the upper abdomen,
however well the swabs are disposed. In the horizontal position the incision
through the lower segment is at a lower level than the abdominal cavity,
and blood and liquor readily escape over the lower end of the abdominal
incision to the exterior.

The abdominal incision is entirely sub-umbilical. The peritoneum
incised is loose. The degree of shock is, therefore, likely to be less than in
a laparotomy in which the abdominal incision partly involves the upper
abdomen, as in the classical operation. When the lateral aspects of thc
abdominal cavity have been packed in the usual way and either Doyen’s
retractor, or a_ self-retaining retractor, introduced at the lower end

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of the abdominal incision, the lower segment is incised. Different types of
incision have been used by various operators. The vertical incision largely
used in Germany has been known to be followed by rupture into the
bladder with fatal result, both during the operation and as the result of the
scar’s giving way during a subsequent pregnancy. A transverse incision
has been used, but may split during extraction of the child with serious
haemorrhage from the uterine vessels. The best incision, according to
Dr. Bailey, is elliptical, the mid-point being a quarter of an inch above the
utero-vesical reflection of the peritoneum and the ends pointing directly
upwards, parallel to the sides of the lower segment. This incision minimizes
the risk of splitting during the extraction of the child, and even if splitting
occurs it is in an upward direction, away from the main vessels at the side.
Owing, no doubt, to the use of this incision, Dr. Bailey has never met this
complication. The aperture in the lower segment resulting from this incision
is the largest obtainable in the area available. It provides, therefore, the
greatest access with the least risk.

The peritoneum is incised and reflected down before the muscle is incised.
The hand of the operator which is nearer to the patient’s feet is then
introduced through the incision and passed to the back of the child’s head.
The other hand retracts the upper flap of the uterine incision, and the
assistant presses firmly and uniformly on the fundus. Thus the head is
shelled out and the body subsequently delivered. During this manoeuvre
the excellent access given by the type of incision described can be
appreciated. Even when the child’s head is jammed in the pelvic brim
there is not any difficulty in extracting it by this method. Dr. Bailey has
never found it necessary to use the forceps at this stage. He does not like
the idea of using a somewhat unwieldly metal instrument inside a space
with a thin wall. He prefers to use his lower hand as elevator and guider.

The uterus is now lifted out through the abdominal incision and made to
contract actively by antero-posterior compression between warm swabs. In
this way the placenta is quickly expressed to the level of the uterine incision,
whence it can easily be removed by traction on its membranous surface.
This procedure makes it unnecessary to remove the placenta by manual
separation in utero, which would increase the risk of sepsis, especially in
cases which are presumably infected before. When the abdominal wall
is abnormally fat or muscular it is often difficult to express the placenta
rapidly if the uterus is allowed to remain within the abdomen, and there is
a temptation to remove it with the hand in utero. Lifting out the uterus
through the abdominal incision is not attended by shock. Dr. Bailey does
not express the placenta per vaginam, because in cases operated on before
labour the dilatation of the cervix is inadequate.

The uterus is sutured with two layers of continuous chromic catgut
number two, the first including the endometrium and half of the muscle,
the second the other half of the muscle and the peritoneum. Thus the
amount of buried catgut is minimized, while the cut surfaces are adequately
apposed. Any slight amount of blood escaping through the incision can
be prevented from reaching the pelvic cavity by the relatively loose
peritoneum between the strands of catgut used in the upper layer. In
potentially infected cases, it is best to stitch the peritoneum separately over
the uterine incision, which itself is closed by two continuous sutures; Scott,

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of Toronto, mentions the layer of fascia which is continuous with the lower
segment, which can be found and closed separately if necessary. He
remarks that this layer is important in helping to keep the infection extra-
peritoneal.

The retractor and swabs are removed, the abdominal and pelvic cavities
are freed from blood, and the abdominal incision is closed.

Results. In this series of 119 cases there were not any maternal deaths.
65 patients were operated upon before labour and were in good condition.
Of the 54 in labour, 15 were in labour for more than 18 hours, and in eight
cases the membranes had been ruptured for more than to hours. In nine
cases the patient had been in labour from 32 to 72 hours and the pulse-rate
was rapid before operation. There were nine cases in which the placenta
was partly occupying the lower segment, and in one case there was ante-
partum haemorrhage on account of this. There were two cases of concealed
accidental haemorrhage and one of eclampsia. Some of the patients with
pulmonary complications were fortunate to survive.

Greenhill reports nine maternal deaths in 807 cases at the Chicago
Lying-in Hospital, a mortality rate of 1.1 per cent. Piper had three maternal
deaths in a series of 73 cases.

Morbidity. The puerperium was morbid in 21 of the 119 cases, i.e. the
temperature reached 100°F. on at least two consecutive days after the third
post-operative day. Of these eight were due to pulmonary complications
and four to urinary infection. Mastitis accounted for two cases of pyrexia.

A reactionary temperature of 1oo°F., or more, was recorded in 21 cases
during the first 48 hours after operation.

Infantile mortality. Six children were stillborn, one being affected with
hydrocephalus and spina bifida: two were associated with concealed
accidental haemorrhage. In one case the mother had valvular cardiac
disease. One child was asphyxiated: one died on the second day after
birth; in this case there was a central placenta praevia and there had been
considerable unavoidable haemorrhage before operation.

Seven of the 119 children, therefore, failed to survive more than two
days after operation—a mortality of 5.9 per cent.

Dr. Bailey then summarized his views on the operation. He believes
that the lower segment technique makes for a sounder result, both in the
immediate post-operative convalescence, in the freedom from remote intra-
abdominal complications and in the freedom from trouble in subsequent
pregnancies. He points out that observation of the uterine incision after
suture, protected as it is from the abdominal contents by the body of the
uterus, which is itself intact, enables one to appreciate the greater post-
operative safety which this operation offers compared with the classical
procedure. He agrees with St. George Wilson in the main points of his
comparison between the two operations: the lower segment technique allows
a trial of labour with the minimum of danger, the mortality is lower, the
convalescence smoother, and the risks during subsequent pregnancies
negligible. He maintains, however, that there is still a definite place for the
induction of premature labour, by mechanical means if necessary. With
Phaneuf, he holds that this technique offers protection against post-operative
peritonitis due to effusion of infected fluid through the uterine incision,
which may occur in the classical operation. He believes also that the post-

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operative intestinal distension, proceeding in some cases to ileus, observed
after the classical operation, is largely due to absorption of the blood which
is squeezed through the incision in the uterine body, by its active contrac-
tions, into the abdominal cavity during the first hour or two after operation.
Danforth says that, even in uncomplicated cases, there are always organisms
in the lower pole of the uterus which will produce a degree of peritonitis if
sufficient blood escapes into the peritoneal cavity.

Dr. Bailey reported before the Society, in 1924, two cases of rupture of
a Caesarean scar, and recorded his belief that the uterine scar had given
way as the result of intra-uterine pressure about the thirty-eighth week of
pregnancy, the scar itself being thin and weak. Since then he had seen
other cases in which the old scar in the uterine body was extremely thin,
stretched and on the point of rupturing. In numerous other cases strong
adhesive bands were present between the uterine scar and the abdominal
wall, or dense omental and intestinal adhesions involved it, giving rise to
chronic symptoms.

He regards his experience as too limited to compare this remote result
with that of the scar of the lower segment operation, the very position of
which, however, prevents its involvement in this way. In the three cases
in which he has operated by this technique for the second time, he has
found the previous scar almost indistinguishable, only a puckering of the
peritoneum marking its site. Two or three cases had also been delivered by
the classical operation some time previously: both showed badly healed
scars and adhesions. It is possible in the classical operation to minimize
the risk of this by careful understitching of the muscle. The fact remains,
however, that it is not a surgically sound procedure to incise a thick,
actively contracting and retracting muscle; healing with a perfect scar
cannot, in such circumstances, be expected. This is of extreme importance,
because the life of a mother and that of a child may depend on it.

Greenhill and Bloom report an examination of 37 cases of repeated lower
segment Caesarean section in which five scars were observed to be very thin.
They believed this to be due to varying degrees of tension produced by the
foetal head near term. Broha says that rupture of the cervical scar is at
least 10 times less common than that of the upper segment scar. He
reports that Tarnier found the scar to be perfect in 26 out of 28 cases in
which the operation was repeated. The continental literature contains the
report of a case of rupture of the cervical scar into the bladder with a fatal
result. A vertical incision had been used and a weak scar had split along
its length. Maxwell records a similar case in which, however, the bladder
was not involved, and the patient recovered. From these facts there is not
any doubt that the cervical incision must not be looked upon as altogether
free from danger. On the other hand, the likelihood of this complication
is relatively remote.

The slightly greater difficulty of the operation, compared with the
classical procedure, is not of any moment to the experienced gynaecologist.
The relatively limited access, the relatively free bleeding in a confined space
while the uterine incision is being made, particularly if the placenta is
praevia, the possibility of difficulty in extracting the head and of tearing
the uterine incision during its extraction are risks, which are minimal if the
semicircular incision is used, and make for the necessity of possessing

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adequate experience. The lower segment operation is not to be undertaken
by the occasional operator.

This operation, named by De Lee laparotrachelotomy and first described
by Frank 27 years ago, has been the subject of much literature since that
time, particularly in America. It has stood the test of time and in America
to-day is performed, in the larger hospitals, almost exclusively under local
anaesthesia.

On the foregoing grounds Dr. Bailey has no hesitation in adding his
views, in support of the efficiency of this technique in all abdominal deliveries,
to those of many authors who have already advocated it as a routine
procedure. In view of his own experience, he stresses the necessity for
observing those details in the technique which he has emphasized in this
paper.

A meeting of the Society was held at Sheffield on Friday, February 23rd,
1934, with the President, Professor DANIEL DouGaL, in the Chair.

Mr. OLDFIELD, of Leeds, showed a specimen of
MALIGNANT TERATOMA OF THE TESTIS IN A GIRL AGED 14.

The patient, D.S., aged 14, was admitted to Dewsbury Infirmary com-
plaining of pain in the right side of the abdomen for three weeks. The pain
was occasional and aching at first; it became severe a week before admission,
and caused her to take to her bed; she vomited when the pain was severe.
Both the pain and the vomiting gradually subsided. She was seen by
Mr. Oldfield two days after admission. She looked like a normal girl of 14.
The breasts were small, the nipples very small. There was a thin covering
of downy hairs on the vulva, which had a normal appearance. The abdomen
was full, resembling the appearance of the abdomen at the sixteenth week
of pregnancy, with an ill-defined tumour at its lower part. A fixed tumour
filling the pelvis was felt on rectal examination. Later the abdomen was
opened in the middle-line, and the tumour exposed: small intestine and
omentum were adherent to it. The tumour was delivered and a good view
of the uterus and right broad ligament was obtained. The tumour was
attached by a broad base to the top of the left broad ligament. The uterus
and right Fallopian tube were small: the right ovary was absent. At the
usual site of attachment of the right ovary a structure of striking appear-
ance was seen. It was porcelain-white, flush with the posterior surface of the
broad ligament, not larger than an impression made by the tip of one’s little
finger; its surface was spotted by tiny cystic projections. In the position of
the ovarian fimbria was another structure, the size of a coffee bean and
egg-shaped: it was white and solid. The tumour and the left Fallopian tube
were removed, the uterus and the other structures were conserved. When a
report had been received from Dr. Carmichael stating that the tumour was
a teratoma with epithelial malignancy, the abdomen was re-opened and the
uterus was removed with most of the right broad ligament. Recovery was
normal. Subsequently a course of deep X-ray treatment was given. When
the child was seen on February 7th, 1934, she had returned to school.
There was not any sign of recurrence. The breasts were flat: the Zondek-
Aschheim test was negative. ‘

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Dr. CARMICHAEL, introduced by Mr. Oldfield, said that on histological
examination he found the structure in the position of the right ovary to be
an atrophic testis. The coffee-bean structure was a typical epididymis.
The tumour itself was a typical tridermal teratoma of the small cystic type:
most of the tissue was fairly well differentiated, but much was still
embryonic, and large portions of a solid area were carcinomatous. It is
assumed to be of testicular origin, partly because teratomata of this type are
fairly common in the testis and very rare in the ovary, and partly because
it is more reasonable to assume that the patient is a pseudo-hermaphrodite
than a true hermaphrodite. The patient’s feminine habitus does not affect
this view, because in cases of pseudo-hermaphroditism with bilateral testes
the secondary sexual characters nearly always conform to the external
sexual organs, and not to the sexual glands.

The PRESIDENT said that he had never seen a similar case. He con-
sidered that the secondary sexual characteristics were largely due to
environment. He asked whether there were any properly substantiated
cases of true hermaphroditism. Dr. Carmichael replied that he did not
know.

Professor MILEs PHILLIPS, of Sheffield, alluded to a case in which he had
seen laparotomy performed for uterine haemorrhage. Testes were found
in the abdomen, and the bleeding from the vagina was traumatic. He
thought that if retained testes were really very liable to malignant change
there should not be any hesitation about removing them.

Mr. Oldfield, in reply, said that the proneness of retained testes to
develop malignant disease was well recognized.

Professor MILEs PHILLIPs showed a post-mortem specimen of

CONTRACTION RING IN THE FIRST STAGE OF LABOUR.

The specimen consisted of a uterus containing a foetus at term and
showing an internal stricture or contraction ring. It had been obtained
from a primipara of 29 years, who died unexpectedly while recovering from
examination under an anaesthetic, during a labour which had lasted for more
than three days. Chloral hydrate, morphine and scopolamine had been
given during the first two days; nembutal (a total of six grains) and chloral
hydrate during the last 10 hours. Oedema of the glottis and slight chronic
renal sclerosis were the only lesions found. There was not any obstetrical
injury. The foetus, weighing eight pounds, lay as a R.O.T. with the head
in the upper part of the pelvic cavity. The contraction ring persisted after
death as a horizontal crescentic ridge with a sharp edge, visible only on the
inner surface of the uterus, exactly opposite the neck of the foetus. It
extended round a third of the circumference of the uterus at this level,
and was 17.5 millimetres thick at its base with a flat upper surface and a
concave lower surface. The thickness of the uterine wall above and below
was only four millimetres, and not more than three millimetres at the
cornua; but there was a small localized thickening, measuring nine milli-
metres, opposite a depression below the knees of the foetus. The cervix
was two millimetres in thickness, and it was not quite half dilated. The
membranes had been ruptured on account of hydramnios when the cervix

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admitted two fingers. Professor Phillips considered that the contraction
ring afforded an explanation of the repeated attacks oi colicky pain which
had distressed the patient during the last 36 hours and which would have
been better treated by repeated doses of morphine and atropine in the
interests of the foetus.

Mr. St. GEORGE Witson, of Liverpool, asked how long after the
morphine was the nembutal given? He knew one anaesthetist who regarded
the combination as extremely dangerous. Mr. Phillips replied that the
morphine was given at 11 p.m. on the 23rd instant, and the nembutal at
9.45 a.m. on the 24th instant.

Dr. GERRARD, of Manchester, mentioned that a death had occurred under
nembutal at St. Mary’s Hospital, Manchester, probably because it was
given in a case of toxaemia.

The PRESIDENT thought that inco-ordinate action of the uterus might be
a cause of shock. He mentioned the case of a Jewess with a contraction
ring, which he had treated by manual dilatation: he considered this a
useful measure.

Dr. J. W. A. Hunter, of Manchester, advocated trachelotomy, on which
he had read a paper to the Society two years before. He had treated 13
cases by it without fatality.

Mr. N. L. Epwarps, of Derby, commenting on the use of amyl nitrite,
said that it was not always successful. He had dealt with a case of
contraction ring in which the forceps had been prematurely applied in a
case of occipito-posterior presentation: amyl nitrite did not have any effect,
and the head was ultimately pulled off.

Mr. OLDFIELD described two cases:

1. WERTHEIM’S OPERATION FOR CANCER OF THE CERVIX PERFORMED DURING
‘LABOUR.

This case is reported in the Journal of Obstetrics and Gynaecology of the
British Empire, 1934, Vol. 41, page 400.

2. MENORRHAGIA CURED BY SPLENECTOMY.

The patient was a girl of 25 years who had suffered from menorrhagia
for three years with resultant relapsing anaemia. Her menstrual periods
usually lasted three weeks. There was not any pelvic cause for the bleeding.
She had been treated at York, after examination under anaesthesia, with
drugs, sera, and injections of whole blood, with little effect. She was
admitted to the Hospital for Women at Leeds in August 1933, and
Dr. Hartfall was asked to examine the blood. There was a deficiency in
the platelets, prolonged bleeding time, and bruising on percussion over bony
points. A purpuric eruption could be produced by venous congestion.
There had never been a purpuric rash or bleeding from other mucous
membranes. The spleen was not palpable and there was not any family
history of splenic disease. Splenectomy was advised and performed by
Lord Moynihan after two blood transfusions. The bleeding time became
normal immediately after the operation. Within six days the platelet count

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had risen from less than 20,000 to 1,000,000 per cubic millimetre. .The
platelets then fell to 500,000 and have since remained about 400,000. A
menstrual period of normal amount lasting four days occurred during the
second week of convalescence. The general condition improved quickly,
and now, nine months after operation, the blood is normal and the patient
is in perfect health. Since operation she had had short, regular periods
and no excessive loss.

The PRESIDENT said that the second case showed the advantage of a
complete examination of the blood in all cases of menorrhagia in which the
cause was obscure.

Mr. A. M. Crave, of Leeds, had treated a case of carcinoma of the
cervix, in the second stage, at term by lower segment Caesarean section,
followed by applications of radium using Héyman’s technique. The first
dose of radium was given 12 days after delivery: the patient was free from
signs and symptoms two years afterwards.

Mr. N. L. Epwarps, of Derby, agreed with Mr. Claye that radium was
the method of choice. He had treated a case on similar lines.

Mr. J. E. Stacey, of Sheffield, had dealt with a case of carcinoma, in
the third stage, during pregnancy in December 1933. The patient was aged
30, and was 31 weeks pregnant: there was much haemorrhage. The radium
director advised radium, and 70 milligrammes were applied to the vaginal
aspect of the cervix for 22 hours. Spontaneous delivery occurred four days
later. Full doses of radium were subsequently given by Heyman’s method.

Mr. Oldfield, in reply, advocated Wertheim’s operation for cases in
stages I and II and radium for the more advanced cases.

Mr. PETER McEwan read a paper on

A Stuby oF HYSTERECTOMY, WITH AN INVESTIGATION INTO THE AFTER-
HISTORIES OF 112 CASES.

One hundred and ninety-six consecutive patients upon whom hyster-
ectomy had been performed in hospital during eight years were asked to
attend in the spring of 1933. Of these 112 came and responded to a
questionnaire. The indication for operation was fibroids in about one-third
(37): all the remainder, except eight, came under a miscellaneous heading of
‘‘endometritis, salpingo-odphoritis and endometriosis’; there were only
three cases of malignant disease, two of the corpus uteri and one of the
cervix. The operation was sub-total in 98, total in 10, and vaginal in four.
Both appendages were removed in 85, and conserved in 12: in 15 they had
been previously removed. Seventy-three of the patients were between 35
and 50 years of age; 26 were younger than 35, 13 older than 50. Of the 112,
all but three were restored to health following the operation.

Mr. McEwan commented on the fact that his miscellaneous group was
large. He said that it was drawn from a class of women who presented
themselves in moderately large numbers at the out-patient department.
Their health is being undermined by pelvic pain, dysmenorrhoea, and
menorrhagia: to these symptoms are often added backache, leucorrhoea,
frequency of micturition, and dyspareunia. The menstrual period has
become a burden. Each period is a blow to their physical and nervous

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energy. They do not recover completely from one before the next arrives.
They gradually become debilitated, unhappy, and neurotic. To these
‘women, in selected cases, hysterectomy is a tremendous boon, and restores
them to comfort and fairly sound health. Care must be taken to exclude
the neurotic woman who has centred her neurosis on her pelvic organs, and
cases in which less drastic treatment may be effective: hysterectomy must
not be done without the intelligent consent of the patient, and if married,
the consent of her husband, and the co-operation of her doctor. The fact
that these cases are more common in hospital work than in private work
shows how greatly the conditions of life reflect upon pelvic symptoms; no
doubt a sea voyage and an easy, healthy life would relieve many: hyster-
ectomy is regrettable, but the verdict of almost every woman in this group
of 67 cases was unhesitatingly, often enthusiastically, in praise of the
operation. Many of them have had one or more children, and date their
troubles from infection at childbirth. Not a few have had one or more
operations and are in danger of post-operative neurasthenia. It may be
argued that when the uterus is not greatly enlarged an artificial menopause
induced by the X-rays or radium would suffice, but, as Green-Armytage
points out, the difficulty of exact diagnosis between endometrioma, malig-
nant disease, inflammatory conditions, and fibroids is an argument of
weight in favour of operative treatment. When the uterus has fulfilled its
essential function of child-bearing or ceased to be capable of producing
children, and the pelvic organs have become a tax on a woman’s physical
and mental well-being, hysterectomy is an invaluable method of restoring
health, and should not be delayed until prolonged pelvic trouble has inflicted
serious permanent damage to the nervous system.

Sub-total hysterectomy was performed unless the cervix was badly torn:
leucorrhoea was cured in 45 of the 50 cases in which it was a feature: its
cure frequently occurred although the cervix was conserved. Mr. McEwan
regards it as a serious omission to leave the appendix unless there is reason
for haste. In this series of cases the conservation of ovarian tissue did not
prevent the occurrence of obesity or the loss of sexual feeling.

Menopausal symptoms were negligible in 27 per cent, slight in 16
per cent, moderate in 26 per cent and severe in 32 per cent. In the severe
cases a constant feature was a history of repeated trauma to the nervous
system, either from dysmenorrhoea, a hard life, or other cause of chronic
nervous exhaustion, sometimes a marital cause. A considerable increase in
weight followed the operation only in 25 per cent of the cases: patients
under 40 were more than twice as liable to obesity as those over that age.
Sexual feelings, in those cases in which it was possible to enquire about
them, remained unchanged in 53 per cent, were increased in five per cent,
diminished in 17 per cent, and disappeared in 25 per cent. Mr. McEwan
doubts whether figures for the normal menopause would be better than
these. He concludes that hysterectomy does not unsex a woman. In con-
‘sidering the question of post-operative neurosis, he emphasizes the need of
-careful explanation of the nature of the operation, not only to the patient,
‘but also to her husband: and he definitely holds the view that the family
doctor should agree to the proposed operation: he considers it wrong to
remove both ovaries if the doctor disapproves. He had four cases of mental
upset in the series. He found that such common symptoms as frequency of

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micturition, backache and leucorrhoea were cured in go per cent, or more,
of the cases. He quotes James Young as having found repair of the torn
cervix very effective in the treatment of gynaecological backache: in nearly
all the cases in this series, however, the cervix was conserved.

The President congratulated Mr. McEwan on his excellent paper. He was
interested in the figures about conservation of the ovaries. His impression
was that many patients were better if the ovaries were left behind: statistics
were valuable in correcting false impressions.

PROFESSOR FLETCHER SHAW of Manchester said that the Manchester tra-
dition was to remove the ovaries, but he had exactly the same impression on
this point as the President. He thought that the menopausal symptoms were
less if the patient was younger. He was surprised at the small percentage of
cases of total hysterectomy in the paper.

PROFESSOR PHILLIPS was impressed with Mr. McEwan’s solicitude for
his patients. He agreed that it was wise to fall in with the family doctor’s
wishes about the fate of the ovaries.

PROFESSOR W. GouGu of Leeds agreed with the Manchester school about
the ovaries. He removed the cervix as a routine, but many practitioners
told him that they preferred subtotal hysterectomy to be done, as the total
operation interfered with marital relations.

Mr. Rawson of Bradford thought that sexual feelings were markedly
altered by the total operation.

Mr. GLyn Davies of Sheffield had been recently engaged in following up
cases of prolapse. Many of these had been treated by vaginal hysterectomy :
the results, as regards cure of symptoms, were about the same after Fother-
gill’s operation as after vaginal hysterectomy. He thought Mr. McEwan

had been lucky in curing so many cases of backache.

Mr. A. GouGuH of Leeds was surprised to hear that sexual feelings could
be rertained after the removal of both ovaries. He had regarded the presence
of an ovary as essential for their retention.

Mr. McEwan, in reply, said that recent papers were in favour of con-
serving ovarian tissue when possible. This probably explained the impres-
sions of the President and Professor Fletcher Shaw.

THE MIDLAND OBSTETRICAL AND GYNAECOLOGICAL SOCIETY.

The second general meeting of the session was held at the Medical
Institute, Birmingham, on Monday, February t1gth, 1934, at 5 p.m. The
PRESIDENT, Dr. C. E. Purslow, was in the Chair.

Professor BECKWITH WHITEHOUSE showed:

Two CLINICAL CASES OF ULCERATION OF THE VULVA, FOR DIAGNOSIS.

Case 1. Miss P., aetat 19 years. The patient was admitted to the
General Hospital, Birmingham, in September 1932, with an ulcer on the
vulva, which she first noticed six months before admission. She had
previously been an in-patient at another hospital, where the ulcer had
proved resistant to all forms of local treatment, and was slowly progressing.

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On admission she had a large ulcer with a shallow base and irregular
margin which involved the posterior extremity of the left labium majus
and the labium minus. It was acutely tender on contact, did not bleed,
and presented a pale grey surface.

The Wassermann reaction was negative, the Mantoux reaction positive.
A radiograph of the abdomen showed a few calcified tuberculous glands
in the right sacro-iliac region. A diagnosis of tuberculous ulceration was
made and the ulcer excised. The tissue, however, showed no evidence of
tuberculosis in the sections examined. The ulcer was reported as ‘‘a simple
granuloma.”’

The girl remained well until December 1933, i.e. 12 months later, when
a small ulcer developed on the right side of the vaginal orifice, which she
attributed to trauma. It is apparently progressing at a slower rate than
the previous one, otherwise it presents very similar characters. She was
readmitted to hospital on February 7th, 1934. Her general condition has
much improved since her first admission 12 months previously: she has .
gained weight. Dr. A. P. Thomson reports that there are no clinical signs
of pulmonary tuberculosis, nor any signs of systemic infection.

It appears that from an early age the girl has been subject to recurrent
ulceration in the mucous membrane of the mouth. She suffered
from pleurisy as a child.

Haemogiobin ... ... ... ... 70 per cent
Lymphocytes... _... . 34.0 per cent

Hyaline and transitional cells... 7.0 per cent
Polymorpho-nuclear leucocytes ... 57.2 per cent

Case 2. Mrs. T., aetat 39 years, was admitted to the General Hospital
Birmingham, on January 28th, 1934, with seven weeks’ history of ulceration
of the vulva. She has one child and has also had two abortions. The
ulcer began as a small pale blue boil, which ruptured and bled. Various
drugs were applied locally, but the ulcer continued to spread. On admission
it involved an area measuring an inch by an inch and a half on the left
labium majus. The base was indurated and sloughing, the edges sharp,
and the discharge clear, with occasional stains of blood. It was acutely
tender on contact. An enlarged tender lymphatic gland was present in the
left inguinal region. The Wassermann reaction was negative.

A biopsy was done on the 30th January. Professor Haswell Wilson
reports that ‘‘the sections show a chronic ulcer apparently of a septic type
with a floor of granulation-tissue in which a great variety of leucocytes is
present. At a deeper level fibrous tissue is being formed. Nothing sugges-
tive of malignancy is seen.’’ Cultures and films from the surface of the
ulcer showed only streptococci and staphylococci; spirochaetes were not seen.

This patient also gave a history of ulcers recurring in the mouth. Since
the age of 17 she has been subject to what she describes as ‘‘sore spots on
the vulva,’’ but these have disappeared under simple local treatment.

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Blood-count. Red _ blood-corpuscles «se 4,080,000
Haemoglobin... ... ... .... 68 per cent
Hyaline and transitional cells ... 8.0 per cent
Polymorpho-nuclear leucocytes ... 73.2 per cent

Discussion.

Mr. A. B. Dansy said that he regarded both these cases as examples of
ulcus vulvae acutum, of which he described four clinical types: (1) a super-
ficial, very tender ulcer with sharply defined edges, which usually recurs if
excised; (2) a rapidly spreading ulceration with abscess-formation; (3) a
miliary type; (4) a gangrenous type. There were no special histological
characters, but a tendency to invasion of the deep layers of the corium.
The disease occurred in young women, and the casual organism was a
Gram-positive bacillus, bacillus crassus.

Cases had been reported in America in association with lesions in the
mouth. Treatment was useless; local applications merely accentuate the
disease. The ulcers should be left alone.

Mr. T. C. CLare said he had seen a similar case in a younger patient and
suggested the possibility of the ulcers being self-inflicted.

Mr. LocHRANE said that these cases were very rare. He did not think
they were of specific type owing to the complete absence of giant cells in the
sections. The microscopic appearances were not those of tubercle, but were,
in a sense, intermediate between those of an acute and a chronic ulcer.
He was sure they were not malignant. He had not had sufficient experience
to give a final opinion on the possibility of such ulcers being due to ésthio-
mene, but they were not like the accepted descriptions of that disease.
Phagedenic, or chancroid, ulceration would cause more involvement of glands
and more general disturbance. There was a possibility that they were a type
of lupus, but he thought it more likely that they belonged to the first of the
four types decribed by Mr. Danby.

Professor STATHAM described a similar but more confusing case which he
had treated. The patient was a married woman with five children. Four
years ago she developed a large red ulcer of triangular shape at the vaginal
orifice. Both labia were enlarged and covered with small depressions with
intervening elevated areas, Wassermann’s reaction was negative. He removed
a portion of the ulcer for biopsy, which was reported as ‘‘chronic ulcer.’’
At different times he had treated her with tuberculin, stabilarsan, tartar-
emetic, and radium; all without effect. He had found it possible to keep it in
check by means of repeated diathermy at intervals of three months. In
this case he had been compelled to diagnose a type of ésthiomene, but there
had never been any involvement of the bladder.

The PRESIDENT said that 20 years previously he had described a case
similar to Professor Statham’s as tuberculous elephantiasis of the vulva. In
this case there was a history of ulceration extending over many years and
of a laparotomy for tuberculous peritonitis. He treated the ulcer by exci-
sion; but it recurred.

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Dr. ParpuHy suggested that the cases should be seen by a dermatologist
before treatment was begun.

Professor WHITEHOUSE, in replying, said that he had not any experience
of the types of ulceration wihch Mr. Danby had described. There was no
direct evidence of self-inflicted injury. Cases of ésthiomene had, in his
experience, always had a positive Wassermann’s reaction. He thought that
the pathology of many cases of ulceration of this type was not yet fully
understood.

Dr. J. MITCHELL then read a paper on

SoME ASPECTS OF THE CHEMICAL COMPOSITION OF HAEMATOCOLPOS FLUID,
which will be published in full elsewhere.

Professor WHITEHOUSE described a case of

SARCOMA BOTRYOIDES, WITH RECURRENCE AFTER 23 YEARS.

which will also be published in full elsewhere.

Mr. T. C. CLareE described a case of

ENDOMETRIOMA OF THE ABDOMINAL WALL.

Caesarean section was performed for contracted pelvis in July 1932. In
January 1934 the patient was seen on account of a small tumour which had
appeared in the scar of the operation. She had noticed the lump for three
months and stated that it became painful during the menstrual periods, but
not at other times. The lump, examined directly after a period, was about
the size of a cherry-stone, and situated in the deeper part of the abdominal
wall, but not adherent to the scar. It was hard and rather tender. <A
diagnosis of endometrioma was made and the tumour was excised. It proved
to be encapsuled by firm fibrous tissue and there was not any sign of infiltra-
tion of the surrounding fatty tissue. It was definitely superficial to the
sheath of the rectus. Sections were prepared and were reported on as
showing scar-tissue among which were scattered acini of mucous glands lined
by a single layer of columnar epithelium embedded in myxomatous tissue
containing fine reticulate cells, Some of the acini contained altered blood.
Microphotographs were shown.

Professor WHITEHOUSE said he had seen two of these cases. The first
was that of a woman who, following ovariotomy many years previously,
menstruated regularly through the abdominal scar. She had an _ endo-
metriosis involving all the pelvic organs, which was too extensive for
operative treatment, but which responded well to deep X-rays. He excised
the ulcer and the patient remained well for years.

The second case occurred in a male, from whom a suppurating appendix
had been removed and a drainage tube inserted. He developed a tumour
in the scar which, after excision, showed all the characters of an endo-
metrioma. He doubted whether Sampson’s theory of origin of these tumours
was always correct, and thought that peritoneal metaplasia explained some
of them.

Professor STATHAM said he had had five cases of aberrant endometriomata
Two of these occurred after the uterine cavity had been opened, for Caesarean
section and for myomectomy. One arose in the scar of an operation for

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radical cure of a hernia which involved the round ligament. The other two
cases were both endometriomata of the umbilicus in women who had never
been operated on. Both these occurred in women of extremely uncleanly
habits, in whom menstrual blood containing fragments of endometrial tissue
might have been implanted into the umbilicus.

Mr. R. L. E. Downer said he had never seen a case of endometrioma
after Caesarean section, but had seen one, after abdominal hysterectomy for
hydatidiform mole, which appeared two years after operation. He had also
seen an endometrioma in the vaginal wall at the fourth month of pregnancy,
which had atrophied during pregnancy, and reappeared six months after
delivery. He suggested that regression coincided with that of the corpus
lueum after the fifth month.

Mr. LocHRANE said he had seen a good many of these cases, and had
excised one five times after ventral fixation, but it had always recurred. The
growths were malignant microscopically, but not clinically. They disap-
peared when all ovarian tissue was removed or destroyed, and showed
decidual reaction during pregnancy. He believed that Sampson’s theory
was correct.

Mr. replied.

Professor WHITEHOUSE then showed a cinematograph film of
A CASE OF PSEUDO-LABOUR.

EDINBURGH OBSTETRICAL SOCIETY

At a meeting of the above Society held on 14th February, 1934, with
the President, DR. OLIPHANT NICHOLSON, in the Chair, Dk. DuGaLtp BatrpD
read a paper on

PYURIA IN THE PUERPERIUM.

Dr. Baird began by stating that infection of the urinary tract frequently
occurred following parturition. In a series of 717 women, in whom the
urine was sterile before delivery, gross infection of the urine developed in
79 cases, 11 per cent. After spontaneous delivery the incidence was five
per cent, and after complicated delivery 25 per cent. When the pyrexia
was notifiable the incidence of pyuria was much greater. In the analysis of
a series of 3,600 consecutive deliveries, it was found that infection of the
urinary tract accounted for about 12 per cent of all cases of puerperal
pyrexia. Exact diagnosis of the cause of the pyrexia. was very difficult in
some cases. About half the cases of pyrexia of urinary origin were due to
exacerbation of chronic pyelitis of pregnancy or to a continuation of the
pyrexia of acute pyelitis of pregnancy. The rest were due to infection
occurring in women in whom the urine was sterile before delivery. In 36
cases the pyrexia was due to septicaemia (8.1 per cent of the total cases of
pyrexia) and of those, 18 were due to coliform organisms. In this latter
group the urine usually became infected and the symptoms were those
associated with pyelitis of the puerperium, viz.: remittent fever, rigors in

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56 per cent of cases, urinary symptoms in 38 per cent, usually very slight
and of short duration, and abdominal discomfort and distension. Predis-
posing factors were difficult delivery and albuminuria of pregnancy. In 52
per cent of cases the time of onset was before the third day and in 34 per
cent the eighth day, or later. In more than 50 per cent of cases an organ-
ism identical to the one in the blood could be isolated from the faeces. Ii
seemed likely that in most cases the organism spread to the vagina ove
the perinaeum, and by means of lacerations, to the blood. These cases had
been termed septicaemic, because the organisms were demonstrated re-
peatedly in the blood-stream, and, as soon as the blood-cultures became
negative, the temperature fell. Stasis was rarely found in the uterus in
these cases and the urinary infection which was produced disappeared
quickly. Pyelitis of the puerperium could be differentiated into two groups
(a) exacerbation of a pre-existing infection and (b) primary infection in the
puerperium. As a rule in group (a) the pyrexia occurred just after delivery
and settled down quickly. In group (b) the pyrexia usually came on later
in the puerperium. Seventeen per cent of puerperal women were found to
have residual urine, which might have become infected, and ascending in-
fection resulted.

Dr. Barctay Dickson then read a paper in which he said that while
carrying out a certain treatment on women in the later months of preg-
nancy, it was incidently noticed that the blood-pressure, when the patient
was lying on her back, was appreciably higher than when she was lying on
her side. Neither treatment, nor time, had anything to do with the differ-
ence because the two observations of the blood-pressure were made within
a couple of minutes of each other, immediately after a treatment had been
given.

The preliminary investigation was conducted on two patients suffering
from pre-eclamptic toxaemia. It then remained to find out if the same
postural difference in the blood‘pressure occurred in all patients, pregnant
or not pregnant, men or women. A series of 30 cases was investigated in
the Royal Maternity and Simpson Memorial Hospital, Edinburgh; the series
included two males. The other cases in the series were taken indiscrimin-
ately from the wards.

The total average difference between the systolic blood-pressure was
10.9 millimetres of mercury and the total average difference in the diastolic
blood-pressure was 12.15 millimetres of mercury; in both cases the blood-
pressure was lower when the patient was lying on her side than when she
was lying on her back.

Possible Cause. Since a difference in the blood-pressure was obtained
whether the patient was pregnant or otherwise, the cause of the difference
could not be solely a mechanical one, due to the compression of the aorta
by the pregnant uterus. It was, therefore, thought that it was due to a
stimulation of the sympathetic plexuses connected with the thoracic and
abdominal arterial systems by the weight of the heart, lungs and gastro-
intestinal tract. This stimulation would come into force, naturally, only
when the patient lay on her back and would cease when she lay on her side.

That injurious stimulation does not occur is indicated in two conditions,
nocturnal incontinence of urine and nocturnal emissions. Both condi-

506

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REPORTS OF SOCIETIES

tions occur, most frequently, when the patient is lying on the back, and
both conditions have been cured when the patients are forced to sleep on
the side.

There is evidence to show that in hyperpiesis the difference between the
diastolic blood-pressure of the patient who is lying on her back and that
of the patient who is lying on her side is very small; in one case quoted it
was only four millimetres of mercury and the patient died later from cere-
bral haemorrhage. The average difference in the diastolic blood-pressure in
the above serires was 12.15 millimetres of mercury. Dr. Dickson wondered
if it might be possible to use the diastolic difference as an aid to immediate
prognosis in cases of hyperpiesis of whatever origin.

A meeting of the Society was held on r9th March, 1934, with the Presi-
dent, DR. OLIPHANT NICHOLSON, in the Chair.

Dr. CHassaR Moir read a paper entitled

RECORDING THE CONTRACTIONS OF THE HUMAN PREGNANT AND
NON-PREGNANT UTERUS.

He demonstrated three types of apparatus.

1. An intra-uterine bag and recording manometer by which contractions
of the puerperal uterus could be recorded.

2. An abdominal apparatus which recorded changes in the shape of the
uterus.

3. An intra-uterine bag which could be used in the non-pregnant uterus.

Suckling usually caused strong contractions of the puerperal uterus.
Ergotoxine, ergotamine, and the alleged new alkaloid sensibamine, all
caused strong contractions of the uterus, but there was a delay of half-
an-hour, or more, before any effect was seen after intramuscular injection.
This lessened their value in postpartum haemorrhage unless they were
combined with a quickly acting drug. Histamine was not effective because
in doses, sufficiently small to avoid unpleasant flushing effects, it had a
negligible action on the uterus. An extract of the pituitary body was reliable
early in the puerperium, but its effect was very erratic after the first week:
in the late puerperium it often failed to produce any activity of the uterus.
Liquid extract of ergot (B.P., 1914 and B.P., 1932) had a powerful, quick
action on the uterus; the effect sometimes appearing in four minutes when
the drug was given by the mouth. It caused marked spasm of the uterus
for an hour, or longer. Its action was entirely different from that of the
alkaloids of ergot. It was this quickly acting factor in ergot which led to
its use by midwives 200 years ago. The intra-uterine injection of glycerine
was not an effective means of causing uterine contractions.

By a double uterine apparatus the contractions from the fundus and
from the cervix were simultaneously recorded. There was some evidence
of a persistaltic wave in the uterus because the contractions of the cervix
lagged about 17 seconds behind those of the fundus.

The non-pregnant uterus showed contractions at all periods of the men-
strual cycle, but these gradually increased in force from the sixteenth day

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JOURNAL OF OBSTETRICS AND GYNAECOLOGY

till the onset of menstruation. During menstruation the contractions exerted
a pressure considerably in excess of that seen during parturition.

The uterus always responded to an extract of the pituitary gland. These
results were contrary to Knaus’s observations published in 1929. Oxytocin
(pitocin) in doses of 10 units, intramuscularly, had no effect on the non-
pregnant uterus, whereas vasopressin (pitressin)) in the same dose had a
very marked effect.

In a case of dysmenorrhoea the intra-uterine pressure rose to surprising
heights. The significance of this in relation to pain was discussed.

:
508

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Full text of "The Journal of Obstetrics and Gynaecology of the British Empire 1934-06: Vol 41 Iss 3"

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